Address for
Correspondence: Dr. Suresh S Pillai, MBBS, D. Ortho, MS
(Ortho), DNB (Ortho), MNAMS, Spine Fellow (Chang-Gung
University, Taiwan), AO Spine Fellow (Nottingham, UK), MCh
(Ortho), Consultant Spine Surgeon, Baby Memorial Hospital,
Kozhikode, Kerala, India. PIN: 673004. E- mail:
sureshorth@googlemail.com
Abstract
Localized abscess at the same site of bacillus Calmette-Guerin
(BCG) vaccine is a known complication. However occurrence of
such abscess at other sites is uncommon. We report a case of a
small child who developed swelling over the thigh following
intramuscular injection at 14 weeks for DPT vaccination.
Histopathology showed caseating granulomatous inflammation and
tuberculosis polymerase chain reaction (TB-PCR) was positive,
culture report came as Acinetobacter species. Specimen was
sent for gene mapping and they isolated BCG strain.
Inadvertent inoculation of BCG vaccine in place of DPT vaccine
at 14 weeks could be a possible reason.
Case report
A small child presented with a swelling over the anterolateral
aspect of thigh. This swelling was noticed for the first time,
after four months of receiving intramuscular vaccination in
the thigh. Vaccination was given at the age of 14 weeks as
part of vaccination schedule, and the swelling was gradually
increasing in size. No history of pain, trauma, fever, weight
loss, cough, and no history of contact with TB patients. On
examination 3 x 2 cm soft, fluctuant, nontender, swelling over
anterolateral aspect of the thigh was noted. Skin over the
swelling was stretched and shiny. There was a BCG scar over
the upper arm. No swelling was noted anywhere else in the
body.
Laboratory tests showed white blood cell count 15,400/mm
3
(25% neutrophils, 57% lymphocytes, 11% eosinophils and 7%
monocytes); hemoglobin 12.5g/dl; erythrocyte sedimentation
rate 9mm/hr; C-reactive protein <1mg/L; liver function test
and coagulation profile were normal; serology for human immuno
deficiency virus (HIV) was negative. Chest X-ray was normal
and X-ray of femur showed no evidence of Osteomyelitis.
USG report showed subcutaneous thick walled collection
extending to intermuscular plane and no evidence of
intramuscular extension, collection measured 2.9 x 1cm.
Needle aspiration done from outside hospital and the aspirate
fluid report came as acid fast bacilli (AFB) stain positive.
Incision and drainage, biopsy was done by us. Intra-operative
findings was around 10-20 ml of thick yellowish pus aspirated
and pus was in the subcutaneous tissue extending into
intermuscular plane and sample sent for gram stain, AFB
stain, culture and sensitivity, TB-PCR and histopathology.
TB-PCR result was positive by DNA amplification for
mycobacterium complex. Gram stain showed gram negative
bacilli; culture report came as acinetobacter species and AFB
stain and culture was negative. Histopathology reported as
Caseating granulomatous inflammation. Same specimen sent for
gene mapping and they identified BCG stain in the specimen.
Child was started on intravenous antibiotics initially after
discussion with pediatrician then once TB-PCR result came,
anti-tubercular drugs started. At present child is 6 month
post op – child is active, growing well and swelling
completely subsided. Case has been reported to the local
health authorities. Consent for publication has been obtained.
Discussion
Cold abscess refers to an abscess that lacks the intense
inflammation usually associated with bacterial infections [1].
In developing world, TB still remains the most common cause
for cold abscess. Isolated cold abscess of the thigh without
active tuberculosis elsewhere in the body is a rare entity and
only a few cases have been reported in the literature [2-6].
As per World Health Organisation (WHO) guidelines, BCG vaccine
is given to newborns at the time of birth through intradermal
route [7]. Cold abscess in the thigh following BCG vaccination
is a known complication reported in the literature [8]. In our
case BCG vaccine was given to the child in the upper arm, as
the scar was clearly visible. But it is difficult to explain
the origin of infection of TB cold abscess in the thigh
following DPT injection.
Two possible explanations could be possible here. One is
tubercular infection at the site of injection following
intramuscular BCG vaccination is given mistakenly in place of
DPT vaccination. Other explanation is syringe contaminated
with BCG strain is used for giving DPT vaccine. Because of the
availability of disposable syringes in the present era for
every vaccination, possibility of contamination seems less
likely.
Conclusion
Cold abscess at intramuscular injection sites following
vaccination could be due to inadvertent administration of
intramuscular BCG vaccine. Correct vaccination techniques
remain the most important factor in the prevention of
vaccine-related complications.
References
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GD. Soft tissue tuberculosis: a series of 11 cases. J
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4. Mishra D, Mohta A and Arora P. Cold abscess of thigh in an
infant. Kathmandu Univ Med J (KUMJ) 2013; 11: 86-87.
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abscess of the thigh in an immunocompetent infant. Trop Doct.
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7. World Health Organization. BCG vaccine. WHO Position Paper.
Wkly Epidemiol Rec. 2004;79(4):27-38.
8. Al Namshan M, Oda O, Almaary J, Al Jadaan S, Crankson S, Al
Banyan E, et al. Bacillus Calmette-Guérin-related cold thigh
abscess as an unusual cause of thigh swelling in infants
following BCG vaccine administration: A case series. J Med
Case Rep. 2011;5:472.