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"Child`s Health" 4 (47) 2013

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Therapeutic approach in surgical complications of BCG vaccination in children

Authors: N.L.Kushch Pediatric Surgery Clinic (Head of the clinic. – M.D., Prof. I.P.Zhurilo), M. Gorkiy Donetsk National Medical University (Rector – corresponding member of Academy of Medical Science of Ukraine, prof. Y.V.Dumansky).

Categories: Pediatrics/Neonatology

Sections: Specialist manual

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Keywords

tuberculosis, complications, BCG (Calmette-Guérin bacillus) vaccination, lymphadenitis, children.

BCG vaccine was first used in 1921. Nowadays about 100 million children receive BCG vaccine every year. BCG vaccine is a live vaccine and when it is used there is a risk of vaccine-related complications. Most complications after BCG vaccination are revealed by regional lymph nodes involvement (axillary, supraclavicular, infraclavicular, cervical) with the development of specific inflammation.

The change of the Russian BCG vaccine to BCG SSI has led to an increase in the number of children with post-vaccination BCG complications in Ukraine. A similar situation was observed previously in other countries. In August 2002 in Ireland and in January 2006 in France, the BCG vaccine SSI was administered to vaccinate against tuberculosis, which led to an increase in the number of complications.

From 30% to 50% of children with BCG vaccination complications needed surgical treatment. The optimal volume of surgical aid in BCG lymphadenitis has not been determined yet. Some authors uphold the method of lymph node contents aspiration. Others insist on changed lymph node conglomerate excision.

The aim of our study was to develop additional criteria of surgical treatment choice of BCG lymphadenitis.

206 children with complications after BCG vaccination (patients aged up to 6 years) underwent treatment in pediatric surgery clinic from 2009 to 2011. There were 127 boys (61.7%) and 79 girls (38.3%). There were 178 children at the age up to 1 year, 28 children from 1 year to 3 years. Senior children were not admitted to the clinic for this period.

Among 206 children the left axillary lymph nodes involvement dominated (135 observations), process was localized in the shoulder lymph nodes (31 patients), supraclavicular lymph nodes (11 patients) and subclavian lymph nodes (11 patients). It was also noted that there was combined axillary and supraclavicular lymph nodes involvement (6 patients), subclavicular and axillary lymph nodes involvement (3 patients), supraclavicular lymph nodes and shoulder involvement (1 child). 4 patients had axillary lymph node involvement on the left with BCG abscess of the left shoulder. 4 patients had osteitis. As a rule, BCG lymphadenitis often occurred in 1-3 months after vaccination (146 patients), after 4-8 months (43 patients), 8-12 months (9 patients).

During the study period there was a progressive increase in the number of complications of BCG vaccination.

All patients underwent ultrasound examination of the affected lymph nodes. If there were signs of purulent fusion of the lymph node confirmed by ultrasound the puncture method was used. Heavy needle puncture was performed under local anesthesia or combined one. Pyogenic abscess was washed with sodium chloride and an aqueous solution of Betadine. Kanamycinum was introduced in recurrent dosage after the evacuation of caseous contents.

In a case of partial dissolution of the lymph nodes conglomerate or puncture technique efficacy surgical removal of the lymph node conglomerate was indicated.

We consider that the choice of surgical treatment of BCG lymphadenitis in the stage of abscess formation should begin with the modified lymph node puncture with aspiration of caseous mass. It allows to avoid the complications associated with general anesthesia during surgical treatment. The manipulation is more effective if most of the lymph node undergo caseous necrosis. The degree of abscess formation is determined by ultrasonography. Doppler sonography allows to determine the nature of the changes in the lymph nodes and to choose a rational therapeutic approach. If areas of intensive blood flow prevailed and there were no avascular zones conservative treatment with anti-TB drugs was recommended. Approximately equal ratio of vascularized areas with purulent destruction areas is considered to be indication for surgical removal of the inflammatory conglomerate. If vascularization is poor against purulent destruction of vast areas the puncture method of treatment was used.

Conclusions:

1) The reason for increasing the number of BCG vaccination complications was change to BCG SSI (Danish strain) in 2008

2) Reversion to the use of Russian vaccine led to decrease in complications of BCG vaccination.

3) U.S. of lymph nodes conglomerate allows to determine the nature of the changes in the lymph nodes in children with complications of BCG vaccination and to choose a rational therapeutic approach.


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