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Citation: Mdhaffer I, Arfa W, Kamoun K, Farah F, Jenzri M. Vaccine-induced tuberculous osteomyelitis.Jr.med.res.2020;3(3): 20-21.
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Case report
Mdhaffer Imed
1,3*
, Arfa Wajdi
1,3
, Kamoun Khaled
1,3
, Farah Faten
2,3
, Jenzri Mourad
1,3
.
Vaccine-induced tuberculous osteomyelitis.
1: Pediatric orthopedics department, Kasab
Institute, Tunis, Tunisia
2: Pathology department, Kassab Institute,
Tunis, Tunisia
3: College of medicine Tunis Tunisia
* Corresponding author
Correspondence to:
i.mdhaffer@gmail.com
Publication Data:
Submitted: August 28,2020
Accepted: October 3,2020
Online: November 30,2020
This article was subject to full peer-review.
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Tuberculosis (TB) has an endemic evolution in Tunisia. Bacille Calmette-Guerin
(BCG) vaccination is systematically provided to all children. The vaccination is
exceptionally complicated by a dissemination beyond the injection site (0.018 case
per 100000 vaccination). We report a case of induced osteomyelitis in one-year old
child following BCG vaccination.
Keywords:
Tuberculosis; BCG vaccine; Osteomyelitis; Management.
Introduction
In Tunisia, vaccination calendar included BCG since 1979. The aim is to protect
children against the spread of primary TB and its severe complications. TB infection
can involve all organs. Tuberculous osteitis and osteomyelitis are rare [1]. The aim
of this work is to highlight the diagnosis circumstances of BCG vaccine-induced
osteomyelitis and the characteristics of its management.
Observation
We report a case of one-year-old child presented for distal left leg pain of 4 months
duration. There was no history of local trauma or fever. Physical examination
revealed edema and tenderness without any ankle motion limitation. X-ray showed
an osteolytic lesion with lateral cortex disruption in distal left tibia and periosteal
apposition (Figure 1a). White blood cells count was 19.5×10³ el /mm³, erythrocyte
sedimentation rate 25 mm/h, C-reactive protein 10.5 mg/L and hemoglobin 10.5
g/dl. MRI showed a distal metaphyseal lesion of the left tibia crossing the lateral
cortex and extending to the distal leg posterior compartment soft tissues. The
contrast sequences showed an intense and heterogeneous enhancement of the
metaphyseal spongy bone with cortex disruption, soft tissue extension and liquid
collection (Figure 1b). There was no involvement of the ankle joint. A surgical
biopsy was indicated to rule out malignancies. The intra operative findings showed
a metaphyseal cavity filled with yellowish gray tissue. The histological analysis
confirmed the diagnosis of tibia tuberculous osteomyelitis. (Figure 2). The growth
of Mycobacterium Bovis in the culture, the absence of immune deficiency and other
location of tuberculosis, and the absence of familial history of TB infection were
arguments to impute this infection to the BCG vaccine. Antitubercular treatment
was provide for ten months. The follow up at 1 year noted no complaints with
satisfactory radiological improvement (Figure 3).
Discussion
BCG vaccine is prepared from attenuated live bovine tuberculosis bacillus strain
[2]. Bone infections are one of the rarest vaccine complications [3] BCG and TB
osteomyelitis are sometimes indistinguishable entities [4]. Five criteria were
proposed to establish the osteitis diagnosis after BCG vaccination: BCG vaccination
in the neonatal period; a period of less than 4 years between vaccination and
symptom onset; no contact between the child and any adults with TB; a consistent
clinical profile; and TB suggestive histopathology [4,5]. Symptoms usually occur
during a period ranging from a few months to 5 years post-vaccination [6]. The
symptoms are non-specific, and the diagnosis is usually delayed. The
histopathologic and bacteriological confirmation is mandatory before proceeding to
a long term antitubercular agents therapy. This case report highlights the
importance of considering the diagnosis of Mycobacterium Bovis BCG osteomyelitis
for all osteolytic lesions in children under 5 years old.
Abstract
Vaccine-induced tuberculous osteomyelitis.
Citation: Mdhaffer I, Arfa W, Kamoun K, Farah F, Jenzri M. Vaccine-induced tuberculous osteomyelitis.Jr.med.res.2020;3(3): 20-21.
Mdhaffer et al © All rights are reserved.
Submit your manuscript: www.jmedicalresearch.com
21
a b
Figure 1a: Xray left Tibia showed osteolytic lesion with lateral cortex disruption in distal left tibia and periosteal apposition.
Figure 1b: MRI features of the lesion with soft tissues edema extension and liquid collection.
Figure 2: epithelioid and giant cells granuloma with caseous necrosis.
Figure 3: Xray follow up at 1 year.
Acknowledgment: This report does not contain any personal information that could lead to the
identification of the patient. A written informed consent was obtained from the parents before the
publication.
Conflict of Interest: None
References
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[2] Cadiou S, Al Tabaa O, Nguyen CD, Faccin M, Guillin R, Revest M, et al. Back pain following instillations of BCG for superficial bladder cancer is not a reactive complication:
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[3] Chiu NC, Lin MC, Lin WL, Wang SY, Chi H, Huang LM, et al. Mycobacterium bovis BCG-associated osteomyelitis/osteitis, Taiwan. Emerg Infect Dis. 2015; 21:539-40.
[4] Gharehdaghi M, Hassani M, Ghodsi E, Khooei A, Moayedpour A. Bacille Calmette-Guérin Osteomyelitis. Arch Bone Jt Surg. 2015; 3:291-95.
[5] Selvestravičius R, Sučilienė E, Saniukas K, Bobelytė O, Usonis V. Sternal Osteomyelitis after Bacillus Calmette-Guérin Vaccination. Pediatr Rep. 2016 19; 8:6626.
[6] Al-Azri MS, Manarang J, Al-Mufargi Y. Bacille Calmette-Guérin Vaccine-Induced Tuberculous Hip Osteomyelitis in an Infant: Case report. Sultan Qaboos Univ Med J. 2017;17:
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