BCG Inoculation Research Articles

Surgical management of BCG vaccine-induced regional axillary lymphadenitis in HIV-infected children.

There are as yet no clear surgical guidelines for the management of BCG vaccine-induced regional axillary lymphadenopathy. The aim of this study was to evaluate the management of the condition and to suggest possible management strategies. A retrospective study was undertaken of 23 cases of suspected ipsilateral BCG adenitis following neonatal BCG inoculation (2001 - 2004). Diagnosis of a BCG infection was confirmed by culture and/or gastric washout. The age of the patient and mode of presentation, imaging findings, and results of tuberculin skin testing (Mantoux test) were documented. Because of a change in management policy the first group of patients treated by primary surgery were compared with those treated by fine-needle aspiration (FNA). The influence of HIV status on outcome was assessed. Surgical complications and outcome were analysed. Twenty-three children under 13 years of age (mean age 8.8 months, male/female ratio 1.9:1) were evaluated. Eighteen patients tested positive for HIV and 5 were HIV-negative. A positive culture for BCG bacillus was identified in 19 cases (83%) - by FNA (N=13, 68%), on pus swab (N=3, 16%), at surgery (N=1, 5%), and by gastric washing (N=2, 11%). Three HIV-negative children had granulomas on histological examination without a positive culture. Forty-five per cent of the 11 patients treated early in the study period by primary surgery (drainage/biopsy) had complications, which included a difficult anaesthetic induction and technical surgical difficulties. The postoperative incidence of wound dehiscence/infection was extremely high in this group and 18.2% developed postoperative cutaneous sinuses. Following a change in management policy, the following 12 patients, with a comparable HIV incidence, treated by initial conservative management, had a much lower incidence of post-procedural complications. This study confirms a high perioperative complication rate associated with the primary surgical treatment of BCG lymphadenitis in both HIV-positive and negative patients. Primary surgical treatment (incisional drainage or biopsy) is therefore not considered an ideal form of management in BCG lymphadenitis because of the high fistulisation and poor wound healing, especially in the HIV-positive patient. It should be avoided as the initial approach, with needle aspiration being preferred. Surgery should therefore be confined to the unusual event of real doubt about the underlying diagnosis and the treatment of suppurative complications.

Processo inflamatório crônico granulomatoso experimental em peixes: um estudo morfológico, ultraestrutural e imunohistoquímico

O objetivo do presente estudo foi avaliar o processo inflamatório crônico granulomatoso induzido experimentalmente em Oreochromis niloticus através da inoculação de BCG e elucidar aspectos da reação inflamatória em peixes para uma melhor compreensão da filogenia do processo. Os resultados obtidos por microscopia de luz comum e ultra-estrutural demonstraram a participação de macrófagos, trombócitos, linfócitos, eosinófilos, células plasmáticas e células gigante tipo corpo estranho no processo inflamatório. Além desses tipos celulares, uma reação granulomatosa constituída predominantemente de células epitelióides também foram observadas ultraestruturalmente. Essas células epitelióides desenvolveram desmossomos ao longo do experimento, e também passaram a expressar receptores para citoqueratina, características estas de células epiteliais. Células pigmentares (melanomacrófagos), envolvendo de maneira crescente toda a formação granulomatóide e, participando ativamente da reação inflamatória crônica granulomatosa.

Lichen scrofulosorum: A prospective study of 39 patients

Lichen scrofulosorum is considered a rare form of cutaneous tuberculosis. Current information is based on case reports and case series with a small number of patients. Thirty-nine patients with Lichen scrofulosorum were followed during the period January 1996 to December 2002. Clinical details (age, sex, duration of disease, associated tubercular lesions, extent and distribution of skin lesions), laboratory parameters (hemoglobin, total leucocytic counts, erythrocyte sedimentation rate, Mantoux test, presence of BCG scar), and response to antitubercular treatment were recorded and analyzed. 7.6% patients of all (511) patients with cutaneous tuberculosis had LS. 22 (56.4%) were males and 32 (84%) were below 15 years of age. Twenty-eight (72%) had an associated focus of tuberculosis elsewhere in the body; 13 (33%) had tubercular lymphadenopathy, while 11 (28%), three (8%) and six (15%) had pulmonary tuberculosis, intracranial tuberculosis and other forms of cutaneous tuberculosis, respectively. Six (15%) had tubercular focus at multiple sites. Eleven (28%) had no other identifiable focus of tuberculosis. Twenty-eight (72%) had evidence of receiving BCG vaccination. Trunk was the commonest (100%) affected site. The two groups with and without associated tubercular focus were not different with respect to age, sex, duration of disease, hemoglobin, total leukocyte count, erythrocyte sedimentation rate, Mantoux test positivity, and presence of BCG scar. Mycobacteria tuberculosis could not be detected either on acid fast bacilli (AFB) staining or on culture from biopsies of LS lesions. All patients (including those without evidence of tubercular focus) responded to antitubercular treatment, signifying an underlying occult tubercular focus as etiology. Lichen scrofulosorum is an uncommon but not rare cutaneous manifestation of tuberculosis. A high index of suspicion and awareness is required for diagnosis. Systemic tuberculosis is often associated with LS and a prior BCG inoculation does not protect against development of LS. Response to antitubercular treatment is good irrespective of the presence or absence of associated tubercular focus.

Clinical Latency and Reactivation of AIDS-Related Mycobacterial Infections

The immune mechanisms associated with the evolution from latent to clinically active mycobacterial coinfection in human immunodeficiency virus type 1 (HIV-1)-infected humans remain poorly understood. Previous work has demonstrated that macaques infected with simian immunodeficiency virus (SIVmac) can develop persistent Mycobacterium bovis BCG coinfection and a fatal SIV-related tuberculosis-like disease by 4 months after BCG inoculation. In the present study, SIVmac-infected monkeys that developed clinically quiescent mycobacterial infection after BCG inoculation were followed prospectively for the reactivation of the BCG and the development of SIV-related tuberculosis-like disease. The development of clinically latent BCG coinfection in these SIVmac-infected monkeys was characterized by a change from high to undetectable levels of bacterial organisms, with or without measurable BCG mRNA expression in lymph node cells. The reactivation of clinically latent BCG coinfection and development of SIV-related tuberculosis-like disease were then observed in these SIVmac-BCG-coinfected monkeys during a 21-month period of follow-up. The reactivation of SIV-related tuberculosis-like disease in these animals coincided with a severe depletion of CD4 T cells and a loss of BCG-specific T-cell responses. Interestingly, bacterial superantigen challenge of the SIVmac-BCG-coinfected monkeys resulted in an up-regulation of clinically latent BCG coinfection, suggesting that infection with superantigen-producing microbes may increase the susceptibility of individuals to the reactivation of AIDS-related mycobacterial coinfection. Thus, reactivation of latent mycobacterial infections in HIV-1-infected individuals may result from a loss of T-cell immunity or from a superimposed further compromise of the immune system.

Low penetrance, broad resistance, and favorable outcome of interleukin 12 receptor beta1 deficiency: medical and immunological implications.

The clinical phenotype of interleukin 12 receptor β1 chain (IL-12Rβ1) deficiency and the function of human IL-12 in host defense remain largely unknown, due to the small number of patients reported. We now report 41 patients with complete IL-12Rβ1 deficiency from 17 countries. The only opportunistic infections observed, in 34 patients, were of childhood onset and caused by weakly virulent Salmonella or Mycobacteria (Bacille Calmette-Guérin -BCG- and environmental Mycobacteria). Three patients had clinical tuberculosis, one of whom also had salmonellosis. Unlike salmonellosis, mycobacterial infections did not recur. BCG inoculation and BCG disease were both effective against subsequent environmental mycobacteriosis, but not against salmonellosis. Excluding the probands, seven of the 12 affected siblings have remained free of case-definition opportunistic infection. Finally, only five deaths occurred in childhood, and the remaining 36 patients are alive and well. Thus, a diagnosis of IL-12Rβ1 deficiency should be considered in children with opportunistic mycobacteriosis or salmonellosis; healthy siblings of probands and selected cases of tuberculosis should also be investigated. The overall prognosis is good due to broad resistance to infection and the low penetrance and favorable outcome of infections. Unexpectedly, human IL-12 is redundant in protective immunity against most microorganisms other than Mycobacteria and Salmonella. Moreover, IL-12 is redundant for primary immunity to Mycobacteria and Salmonella in many individuals and for secondary immunity to Mycobacteria but not to Salmonella in most.

Pathologically Normal Coronary Artery after Kawasaki Disease: A Case Report

It is well known that the sequelae of the vasculitis are observed pathologically in the coronary arteries of the patients with Kawasaki disease. It has been reported that these abnormal findings are commonly detected even in patients with clinical diagnosis of normal coronary arteries. We experienced a case of Kawasaki disease without clinically and pathologically significant coronary artery lesions. A 1 year 0 month-old male infant had an episode of Kawasaki disease. The diagnosis was established from the 5 principal clinical findings except lymphadenopathy. He also had redness of the skin at the site of BCG inoculation. He was treated with intravenous gamma globurin(1g/kg) administered two times. Echocardiographic evaluation of the coronary artery was carried out several times during the acute phase of the illness until 2 months after the onset of the disease, and no abnormal findings were obtained. His clinical diagnosis was complete recovery from the Kawasaki disease. He died suddenly when he was 2 years 1 month old. He had a febrile episode at night, and in the next morning, he was found dead. From the macroscopic autopsy findings, the cause of the death was diagnosed as an acute bronchitis. Histologically, the coronary arteries had normal architecture, and no particular sequelae of arteritis were found. Scar formation was not detected. Mild intimal thickening was observed in the proximal portion of the bilateral coronary arteries, but it was not thought to be pathologically significant. Distal portion of the coronary arteries were normal. Myocarditis and myocardial ischemia were also excluded. From these findings, we concluded that there were patients with complete recovery from Kawasaki disease, not only clinically but also pathologically. This fact may influence the follow up methods of the patients with clinically complete recovery from Kawasaki disease.

A Case of Hyper IgE Syndrome with Severe Ulcer and Granuloma at the Site of BCG Inoculation

A Case of Hyper IgE Syndrome with Severe Ulcer and Granuloma at the Site of BCG Inoculation

Exposure to Mycobacterium avium primes the immune system of calves for vaccination with Mycobacterium bovis BCG.

The objective of the investigation was to provide data on how a prior exposure of cattle to Mycobacterium avium, used here as a model of exposure to an environmental mycobacterium, affected the cellular immune response that follows vaccination with Mycobacterium bovis BCG. The assessment of cellular immune responses included lymphocyte proliferation assays, the delayed hypersensitivity skin test and IFN-gamma synthesis in whole blood cultures. One group of calves was inoculated subcutaneously with M. avium followed 12 weeks later by M. bovis-BCG. The other group was vaccinated subcutaneously with BCG alone. Calves previously exposed to M. avium responded more rapidly, as assessed in the in vitro assays, to purified protein derivative (PPD) from M. avium (PPD-A) or M. bovis (PPD-B) than did calves inoculated with BCG only, indicating that the exposure to M. avium had primed the immune response in these calves. Following inoculation of BCG the intensity of the in vitro responses and the delayed hypersensitivity skin test to PPD-A was higher for the M. avium-primed animals while the responses to PPD-B were similar in the M. avium-primed and BCG-only groups. The results are consistent with a model in which prior exposure to environmental mycobacteria does not necessarily inhibit the immune response to the vaccine strain, BCG. They suggest that M. avium infection primes the immune system of calves and that the detection of an immune response specific for M. bovis BCG is masked by reactivity to antigens also present in M. avium.

In vivo T-lymphocyte activation and transient reduction of viral replication in macaques infected with simian immunodeficiency virus.

While it is well established that cellular activation can increase human immunodeficiency virus (HIV) replication in T lymphocytes, it is also clear that both activated CD8+ and CD4+ T lymphocytes mediate anti-HIV activity. To assess the relative importance of these contrary effects on HIV replication in vivo, we evaluated the consequences of Mycobacterium bovis BCG and staphylococcal enterotoxin B (SEB) inoculation in vivo in rhesus monkeys chronically infected with simian immunodeficiency virus of macaques (SIVmac). BCG inoculation induced as much as a 2.5-log reduction of plasma and intracellular SIV RNA in SIVmac-infected monkeys. This down-regulation of virus replication persisted as long as 4 weeks after BCG inoculation. Similarly, SEB injection resulted in up to a 3-log decrease in plasma and intracellular SIV RNA in SIVmac-infected macaques. Interestingly, the short-term reduction of viremia in these monkeys correlated with the peak in vivo production of SEB- and BCG-induced cytokine responses. However, no long-term clinical benefit was observed in the SIVmac-infected macaques. These studies provide in vivo evidence that potent T-cell stimulation driven by antigens other than the virus itself can, under some circumstances, mediate short-term reduction of viremia in AIDS virus-infected individuals.

Une septicémie à Mycobacterium bovis «souche BCG»: faut-il utiliser les corticoïdes en association avec les antituberculeux ?

Clinical case – We report two cases of mycobacterial sepsis after intravesical BCG immunotherapy in superficial bladder tumors. In both cases, patients had experienced a traumatic catheterization. Case n°1: A 64 year old man was admitted to hospital with septic shock, following the second BCG inoculation. During 3 weeks, he received a course of ciprofloxacine, but his condition did not improve. A liver biopsy showed granuloma with multinucleated giant cells. The patient received anti-tuberculous drugs and corticosteroids after a liver biopsy. His condition improved, fever disappeared, and liver enzymes slowly returned to normal values. Case n°2: A 70 year old man had similar presentation following the third inoculation: sepsis and multi-organ failure. A blood culture proved positive with M. bovis. He was treated withanti-tuberculous drugs and corticosteroids and his conditions rapidly improved. Comments – Our study results favor the use of corticosteroids in association with anti-tuberculous agents.

Disseminated BCG infection: a four case study

BCG inoculation at birth has been compulsory in our country since 1959. Adverse reactions induced by BCG vaccination are rare, ranging from zero to 23.8%. Disseminated infections are even rarer and their estimated incidence is 0.1 to 4.3 per one million vaccinated children. Lethal disseminated BCG infection is exceptional and affects especially the children presenting an immune deficiency. A familial gene defect may play a role. BCG osteitis is second to suppurative lymphadenitis in clinical forms; it generally develops five months to five years after vaccination. We report four cases of disseminated BCG infection occuring in children from three months to four years of age, leading to death in two cases. Our objective is to discuss the pathologic aspects of BCG infection.

幼児に発症した結核性膝関節炎（骨髄炎）２例

Last year, we experienced 2 infant case of tuberculosis osteomyelitis of the knee. Soon osteomyelitis became apparent in one case from the side effects arising from BCG inoculation, and from the results of the sensitivity test of the bacteria that collected. The report of BCG side effects in Japan is considerably less compared with several foreign countries. Until now, the total number of reported BCG osteomyelitis case in Japan has been 9, including our own. This includes even case studies of reports in other articles about the case and report.

Purified protein derivative anergy in Kawasaki disease.

It was previously reported from Italy that all patients with Kawasaki disease had a positive tuberculin intradermal test. In this study from Seattle, WA, nine patients with Kawasaki disease showed no reaction to intradermal tuberculin. The difference in results might be caused by the different tuberculin products.

Effect of mycobacterial infection on virus loads and disease progression in simian immunodeficiency virus-infected rhesus monkeys.

The effect of a mycobacterial infection on AIDS disease was studied in the simian model. Monkeys were infected with the primary virulent isolate SIV/DeltaB670 and inoculated 90 days later with BCG, an attenuated strain of Mycobacterium bovis. All monkeys experienced a dramatic transient increase in plasma viremia and CCR5 expression on T lymphocytes after BCG inoculation. Only two of the four SIV+ animals had substantial proliferative responses to PPD, with poor responders developing disseminated BCG during the course of the experiment. BCG inoculation of SIV-infected long-term nonprogressor (LTNP) monkeys was also performed. Similar to the acutely infected animals, two of three LTNPs experienced increases in plasma viral levels and CCR5 expression. In the majority of animals studied, there was no accelerated progression to AIDS despite the concomitant transient stimulation of virus replication and CCR5 expression on T lymphocytes.

Immunization monitoring of students starting school: a regional contribution from the Bavaria district

The aim of these sectional studies was to find out current mass immunisation rates of school beginners. The study was carried out in the administrative district of Dingolfing-Landau in 1999, also to examine to what extent the recommendations to the STIKO (Established Immunisation Committee at the Robert Koch-Institute) for the corresponding age-group had been complied with. To this end, the vaccination documents submitted at the medical examination were inspected, the given data recorded in a standardised way and subsequently rendered anonymous. According to the available results the mass immunisation rates for diptheria, tetanus and polio met the infection epidemiology requirements by over 90%. The HiB, MMR and whooping cough vaccinations were in on the average 80% for mass immunisation, which no longer meets the epidemiological requirements. BCG inoculation was only given to every tenth child in the relevant age group. A positive aspect was the comparatively high immunisation rate of almost 50% on hepatitis B immunisation. Only one child in twenty in the relevant age group had the full immunisation protection recommended by STIKO. Due to the great acceptance and willingness to co-operate on the part of the parents/legal guardians the review of the immunisation status through the Childrens and Young People's Public Health Authority (KJGD) made it possible to establish the current mass immunisation rate for children of one birth year. In this way, it will be possible by means of relevant immunisation recommendations and immunisation strategies to close the immunisation gaps and raise the mass immunisation rates.

Antigenic stimulation by BCG vaccine as an in vivo driving force for SIV replication and dissemination.

The impact of antigenic stimulation on the dynamics of simian immunodeficiency virus (SIV) replication was studied following repeated intravenous BCG inoculation of a SIV infected macaque. At the site of a delayed type hypersensitivity reaction to purified protein derivative of M. tuberculosis, a distinctive SIV variant was noted, probably as a result of the infiltration of activated antigen-specific T cell clones as opposed to infection by blood borne virus in situ. The dynamics of SIV quasispecies in peripheral blood suggests sequential waves of viral replication, illustrating the role of antigenic stimulation as a driving force in viral dissemination and pathogenesis.

Analysis of children with tuberculosis in the past 20 years

To characterize the clinical features of childhood tuberculosis, we analyzed the symptoms, signs, and laboratory findings of the 89 children with tuberculosis admitted to the Yokohama City University Hospital from 1975 to 1994. Compared with the numbers of patients admitted from 1975 to 1979, those of patients of the past 5 years (from 1990 to 1994) were reduced by half. Of the 89 subjects, 56.2% were below 3 years of age and 24.7% were under 1 year of age. 51.7% had primary complex and 20.2% had serious tuberculosis (tuberculous meningitis 14.6%, miliary tuberculosis 3.4%, and bone and joint tuberculosis 2.2%). Tuberculous children below 3 years of age consisted of primary complex (60.0%) and serious tuberculosis (32.0%). The majority (86.0%) of tuberculous children below 3 years of age had not received BCG vaccination. In 55 (61.8%) of 89 subjects, the sources of tuberculosis were clarified. Of these subjects, 83.6% were infected in the family. The rate of BCG inocluation tended to decrease with decreasing age, especially that of children below 3 years of age was 14.0%. Of the 89 subjects, only 16.9% proved to be smear-positive. Taken together, in order to eliminate tuberculous children below 3 years of age, the following is necessary; (1) BCG inoculation in early infancy, (2) early diagnosis of index cases with adult tuberculosis, and (3) prompt and appropriate family contact examination.

川崎病とストレス蛋白

Kawasaki disease, an acute febrile illness which affects infants and young children, is characterized by diffuse mucosal inflammation, indurative edema, polymorphous rash, and nonsuppurative cervical lymphadenopathy. About 15-20% of patients suffer coronary arterial damage, and they may develop myocardial infarction, chronic coronary insufficiency, and sudden death. Since Kawasaki originally described this disease entity in 1967, the number of such patients in Japan has reached 100, 000.While the etiology is still unknown, the epidemiological features of this disease indicate that it is related to an infectious agent. Immunologically, both a highly increased level of several cytokines and the activation of immunocompetent cells have been demonstrated. Pathology have revealed that the vascular lesion begins with endothelial cell damage, the initial step of which may be activation of the endothelial cell to express ICAM-1 and ELAM-1 by cytokines. Thus, the etiologic factor (s) would predispose to an activation of both the immune system and the endothelial cells.Some mitogenic materials including superantigen, stress protein, and so forth, would be the candidates. According to the clinical findings, inflammatory changes at the site of a previous BCG inoculation seems to be an early and specific manifestation of Kawasaki diseasse. We postulated that molecule (s) that are cross-reactive between the suspected infectious agent and the mycobacterial BCG antigen may contribute to this inflammatory process. Using BCG lysates or recombinant stress protein, HSP65, as antigen for Western blotting, convalescent, but not acute, phase sera of Kawasaki disease did react with HSP65 antigen, suggesting bacterial stress protein may be the causative agent which abnormally activate immune system. Moreover, epitope mapping of human mitochondrial protein, P1 antigen, indicated that convalescent phase sera of Kawasaki disease contained autoantibody to this human HSP65 cognate antigen.Thus, Kawasaki disease may be induced by the exposure of bacterial HSP65, and recognition of autologous HSP65 cognate antigen by activated immune system may exaggerate the autoimmune response.

Presence in Kawasaki Disease of Antibodies to Mycobacterial Heat-Shock Protein HSP65 and Autoantibodies to Epitopes of Human HSP65 Cognate Antigen

The central features of Kawasaki disease are immune activation and cytokine-mediated generalized vasculitis. To identify the predisposing factors, we examined the antibody response to BCG antigens, since reactivation of a previous BCG inoculation site is an early, specific manifestation of this disease. BCG antigens were separated on SDS-PAGE, transferred to membrane, and incubated with acute- and convalescent-phase sera of 21 patients with Kawasaki disease. Sera were also examined for the presence of antibodies to mycobacterial 65-kDa heat-shock protein (HSP65), and to its human homolog P1 antigen using synthetic peptides of nonhomologous region. To demonstrate the HSP65-sensitized T cells, in vitro proliferation assay was performed. All convalescent, but not acute phase, sera showed a strong antibody reactivity against 65-kDa protein. The reactivity was directed to recombinant HSP65. Non-crossreactive sequences between rHSP65 and human HSP65 cognate were synthesized. The sera recognized these peptides of rHSP65 and autologous P1 antigen. Peripheral lymphocytes proliferated following the addition of rHSP65 (stimulation indices, 2.16-7.82; mean, 4.54). These findings suggest that HSP65 may be the most potent factor predisposing to Kawasaki disease, and that an autoreactivity to the epitope of the human HSP65 homolog may be related to the susceptibility to the disease.

Neutralization of gamma interferon and tumor necrosis factor alpha blocks in vivo synthesis of nitrogen oxides from L-arginine and protection against Francisella tularensis infection in Mycobacterium bovis BCG-treated mice.

Peritoneal cells from Mycobacterium bovis BCG-infected C3H/HeN mice produced nitrite (NO2-, an oxidative end product of nitric oxide [NO] synthesis) and inhibited the growth of Francisella tularensis, a facultative intracellular bacterium. Both NO2- production and inhibition of bacterial growth were suppressed by NG-monomethyl-L-arginine, a substrate inhibitor of nitrogen oxidation of L-arginine, and monoclonal antibodies (MAbs) to gamma interferon (IFN-gamma) and tumor necrosis factor alpha (TNF-alpha). Intraperitoneal injection of mice with BCG increased urinary nitrate (NO3-) excretion coincident with development of activated macrophages capable of secreting nitrogen oxides and inhibiting F. tularensis growth in vitro. Eight days after BCG inoculation, mice survived a normally lethal intraperitoneal challenge with F. tularensis. Treatment of these BCG-infected mice with MAbs to IFN-gamma or TNF-alpha at the time of BCG inoculation reduced urinary NO3- levels to those found in normal uninfected mice for up to 14 days. The same anticytokine antibody treatment abolished BCG-mediated protection against F. tularensis: mice died within 4 to 6 days. Intraperitoneal administration of anti-IFN-gamma or anti-TNF-alpha antibody 8 days after BCG infection also reduced urinary NO3- and abolished protection against F. tularensis. Isotype control (immunoglobulin G) or anti-interleukin 4 MAbs had little effect on these parameters at any time of treatment. IFN-gamma and TNF-alpha were clearly involved in the regulation of macrophage activation by BCG in vivo. Protection against F. tularensis challenge by BCG depended upon the physiological generation of reactive nitrogen oxides induced by these cytokines.