Surgical management of post BCG vaccine lymphadenitis, comparative retrospective study

Surgical management of post BCG vaccine lymphadenitis, comparative retrospective study

Mohamed  E Hassan, MD, FEBPS

Department of Pediatric Surgery, Zagazig University, Egypt.

Introduction: Adverse  reactions  following  BCG  vaccination  are  uncommon,   with  an estimated prevalence of 0.4 per 1000 vaccines. The options for surgical management  of post BCG vaccine suppurative lymphadenitis  are incision  and drainage, total excision, or simple needle aspiration. The aim of the study is to compare the outcome of surgical treatment of suppurative post BCG lymphadenitis using simple needle aspiration versus primary excision.

Patients and methods: A retrospective file review was done for all children who presented, with a diagnosis of post BCG vaccine suppurative lymphadenitis (axillary and/ or supraclavicular), to the pediatric surgery clinic in two tertiary pediatric surgery  centers during the period from January 2007 to January 2013.

Results:  The study population included 91 patients, 38 in Group 1 versus 53 in Group 2. There were 60 males and 31 females. Two groups  were identified in the  study, according to the type of management  at the initial presentation, Group 1 who were managed with simple needle aspiration and Group 2 who were managed with primary surgical excision. Patients who received antituberculous treatment were excluded from the study.

Conclusion: Primary  surgical excision  for post BCG  suppurative  lymphadenitis  showed better outcomes than needle aspiration in the current study population.

Key words: BCG, vaccine, lymphadenitis, children.

Introduction:

Bacillus  Calmette-Guerin (BCG)  is a live attenuated vaccine to prevent tuberculosis, routinely administered at birth as part of the World Health  Organization global  expanded immunization program.l

Adverse  reactions  following BCG vaccination are uncommon, with an estimated prevalence   of    0.4   per    1000    vaccines.2

Complications include  erythema, blistering, abscess   formation,  regional    lymphadenitis and keloid formation.3

The  options  for  surgical  management of

post BCG vaccine  suppurative lymphadenitis are incision and drainage, total excision, or simple needle aspiration. The choice of surgical management remains controversial.4-8

The aim of the study is to compare the outcome  of surgical  treatment of suppurative post BCG lymphadenitis using simple needle aspiration versus primary  excision.

Patients and methods:

A retrospective file review was done for all children  who  presented,  with  a diagnosis of post BCG vaccine  suppurative lymphadenitis (axillary  and/  or supraclavicular), to the pediatric   surgery  clinic  in  two  tertiary pediatric   surgery   centers  during  the  period from January  2007 to January  2013.

Children with  nonsuppurative lymphadenitis were excluded  from the study.

Suppuration has been defined as "presence of  fluctuation  on  palpation   or  pus  on aspiration,  the  presence  of a sinus,  or  large lymph node adherent to the skin with caseous lesions on excision".9

Two groups were identified in the study, according  to  the   type   of   management  at the initial  presentation, Group  1 who were managed with simple  needle aspiration and Group  2 who were managed with primary surgical    excision.    Patients    who   received

antituberculous    treatment    were    excluded from the study.

For Group 1, aspiration was done weekly for the first one month then monthly for 4 months  (if  during  follow  up no fluctuation were observed, no aspiration was done). The aspiration  was  done in the outpatient  clinic under  complete   aseptic  technique   with  a

19 Gauge needle and was sent for AFP and routine culture sensitivity test.

All patients in group 2 received a single dose of Amoxicillin/ Clavulonic acid before surgery.

Data       collected       included,       patients

demographics, site of suppurative lymphadenitis, the duration between BCG vaccination and suppurative lymphadentitis, number   of  aspirations,   culture   results   of the pus in both groups, time to complete resolutions (calculated as the time frame from the first clinic visit till complete resolution of the suppurative lymphadenitis), the incidence of failed aspirations  in group  1 and the incidence of wound infection in group 2.

Data   were   tabulated    and    statistically

analyzed using SPSS version 17, Chi square and  t tests  were  used to  test  for  statistical significant  difference  between  both groups. P <0.05 was considered as statistically significant difference.

Results:

The study population included 91 patients,

38 in Group  1 versus  53 in Group  2. There were 60 males and 31 females Table (1).

There   was   statistically   significant   less

time  in group 2 for the complete  resolution of the post BCG suppurative lymphadenitis, Table (2).

There were  39%  ( 15 patients)  in group

1 who failed to be treated with frequent aspiration who were subjected for complete excision of the suppurative lymphadenitis. Postoperative infection in group 2 was encountered  in 19% (10 patients), (X2 = 4.7, p <0.05).

Discussion:

Bacillus Calmette-Guerin (BCG) vaccine has a good safety profile in immune competent

children and considerable risks such as disseminated   BCG  disease   in   individuals with immune deficiencies. However, some complications, including local subcutaneous infection, regional suppurative lymphadenitis may occur after BCG vaccination in immune competent children.10

Lymphadenitis presenting within 2 months of vaccination and larger nodes(+ 1cm) may be   less  likely  to   resolve   spontaneously.6

The  onset  of  suppuration  may  be  variable with cases presenting from one week to 11 months  following  vaccination  (de  Souza  et al., 1983).11 Mean age at presentation ofthe current study was 3.5 versus 4.3 months for group 1 and 2 respectively.

The current study populations didn't show any statistical significant differences in the patient's demographic data. The time required for development of post BCG suppurative lymphadenitis and the site of suppurative lymphadenitis was not different statistically between both groups.

53%  versus   60%   in   group   1  and   2

respectively,  showed  positive  AFB  cultures of the collected fluid. Bolger et ai12 isolated

46% AFB in his study  population from post

BCG suppurative lymphadenitis.

None of our patients in the study were treated  with  antituberculuos  medications. Two studies, one comparing isoniazid with erythromycin13  and  the  other  a  controlled

placebo   study, 14  showed   no  clear  benefit

from the use of either of these 2 agents for the treatment of suppurative lymphadenopathy. There  is  no  convincing  evidence  that medical interventions, including  use of anti­ tuberculous agents, hasten recovery.15,16

The time required for complete treatment of the post BCG suppurative lymphadenitis was  135  versus  48  days  in  group  1  and

2    respectively,    which    was    statistically

significant.

39% in group1 failed to be treated with frequent aspiration, which is considered a complication ofthis type of surgical treatment.

19% in group 2 who developed postoperative

wound infection were treated according to wound  cultures. 7 versus 3 wounds  showed

gram positive  and gram negative  organisms

m-     ams      ur;g_      4;    _:        -

Table 1: Demographics of both groups.

Table 2: Variables in both groups

respectively,  which   required  local   wound care and topical  antibiotics. None  of the infected  wounds  grew AFB cultures.  Bolger et al isolated Staphylococcus aureus from five patients out of25 (20%) who required surgical excision of suppurative lymphadenitis.l2

Conclusion :

Primary surgical exclSlon of post BCG suppurative  lymphadenitis  was   associated with statistically significant less time for complete surgical treatment  than needle aspiration. Primary  surgical  exc1s10n was associated   with   less   surgical   complication rate  than  the  aspiration group.  Primary surgical excision for post BCG suppurative lymphadenitis    showed     better     outcomes than needle aspiration  in the current study population.

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