Case Letter
Bacillus Calmette-Guérin vaccine-induced lupus vulgaris in a 3-year-old child
Nisha V. Parmar
, Amani Al Falasi, Alia Almualla
Corresponding author
Dermatology Centre, Dubai Health Authority, Dubai, United Arab Emirates
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Parmar, Amani Al Falasi, Alia Almualla" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Nisha V." "apellidos" => "Parmar" "email" => array:1 [ 0 => "parmarnish@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Amani" "apellidos" => "Al Falasi" ] 2 => array:2 [ "nombre" => "Alia" "apellidos" => "Almualla" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Dermatology Centre, Dubai Health Authority, Dubai, United Arab Emirates" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1218 "Ancho" => 905 "Tamanyo" => 299452 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A), Granulomatous infiltration in upper and mid-dermis. (B), Non-caseating epithelioid cell granuloma with peripheral lymphocytic rim.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 3-year-old girl presented with an asymptomatic lesion on the left upper arm of 2 years’ duration. The lesion started as a papule at the site of Bacillus Calmette-Guérin (BCG) vaccination scar at the age of 1 year and gradually enlarged to its present size. She had no constitutional symptoms and was otherwise well. There was no history of contact with an active case of Tuberculosis (TB). General and systemic examinations were normal. Cutaneous examination revealed an erythematous plaque measuring 5×4 cm with thick adherent scales and fingerlike extensions on the left deltoid region (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Clinical differential diagnoses considered were BCG vaccine-induced lupus vulgaris, chromoblastomycosis, psoriasis, and discoid lupus erythematosus.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Routine hematological investigations showed a raised erythrocyte sedimentation rate. Her chest X-Ray was normal. Serology for HIV was negative. A skin biopsy of the plaque revealed non-caseating epithelioid cell granulomas with a rim of lymphocytes in the upper and mid dermis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Acid-fast bacilli and periodic acid-Schiff staining of biopsy specimen were negative. Cultures of the skin biopsy were also negative for mycobacteria and fungi. Mycobacterium (M) tuberculosis complex DNA detection via Polymerase Chain Reaction (PCR) of the biopsy specimen was negative. Interferon-gamma release assay using the Quantiferon TB gold test was also negative. Based on the site of lesion, clinical morphology, and presence of epithelioid cell granulomas in histopathology, the possibility of BCG vaccine-induced lupus vulgaris was considered and a trial of antitubercular therapy was commenced. <span class="elsevierStyleItalic">M. bovis</span> is inherently resistant to pyrazinamide and ethambutol is avoided in children due to its ophthalmologic side effects.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The child thus received a regimen consisting of rifampicin (6 mg/kg/day) and isoniazid (5 mg/kg/day) from the Pediatric Infectious Disease unit. The lesion healed completely after 2 months of therapy (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). A final diagnosis of BCG vaccine-induced lupus vulgaris was thus made.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The BCG vaccine is composed of a live attenuated strain of <span class="elsevierStyleItalic">M. bovis</span>. It is routinely administered to all neonates in high endemic countries to prevent the more serious forms of tubercular infections such as meningoencephalitis and miliary tuberculosis in children.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Cutaneous complications of the BCG vaccine in the immunocompetent host include the common local reaction to the vaccine and uncommon reactions. The local reaction occurs 2–6 weeks post-vaccination as a small papule that may discharge purulent material, enlarge to form a shallow ulcer which scars. The rare complications include BCG granuloma, injection site keloids, lupus vulgaris, scrofuloderma, tuberculids, fixed drug eruption, and BCG granulomas occurring during the course of Kawasaki disease.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">BCG vaccine-induced lupus vulgaris occurs in 5 per million vaccinations.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It is commoner after multiple vaccinations and usually manifests after 1 year of vaccination. Lupus vulgaris is a paucibacillary form of cutaneous tuberculosis that occurs either via hematogenous spread or direct inoculation. A skin biopsy is helpful in obtaining a histopathological diagnosis. Other confirmatory tests for tuberculosis may be inconclusive as in our patient. A high index of suspicion is required for the diagnosis and a trial of antitubercular drugs is warranted.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0030" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors’ contributions</span><p id="par0035" class="elsevierStylePara elsevierViewall">Nisha V Parmar: Conception and planning of the study; critical review of the literature; obtaining, analysis, and interpretation of the data; elaboration and writing of the manuscript; critical review of the manuscript. approval of the final version of the manuscript.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Amani AlFalasi: Approval of the final version of the manuscript; obtaining, analysis, and interpretation of the data; critical review of the manuscript.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Alia AlMualla: Approval of the final version of the manuscript; obtaining, analysis, and interpretation of the data; critical review of the manuscript.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Authors’ contributions" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-07-04" "fechaAceptado" => "2020-07-21" "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Parmar NV, Al Falasi A, Almualla A. Bacillus Calmette-Guérin vaccine-induced lupus vulgaris in a 3-year-old child. An Bras Dermatol. 2021;96:636–8.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Dermatology Centre, Dubai Health Authority, Dubai, United Arab Emirates.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 793 "Ancho" => 905 "Tamanyo" => 80989 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Well-demarcated erythematous scaly plaque with centrally adherent thick scales and finger-like extensions measuring 5×4 cm at site of BCG vaccine scar on left deltoid region.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1218 "Ancho" => 905 "Tamanyo" => 299452 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A), Granulomatous infiltration in upper and mid-dermis. (B), Non-caseating epithelioid cell granuloma with peripheral lymphocytic rim.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1078 "Ancho" => 905 "Tamanyo" => 131525 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Scar at site of lesion post-treatment.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lupus vulgaris due to Mycobacterium bovis bacillus Calmette-Guérin (BCG) at the site of previous BCG vaccination" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "S.L. Walker" 1 => "S. Lozewicz" 2 => "R. Sood" 3 => "T.A.N. Mann" 4 => "E. Campalani" 5 => "V.G. Hubbard" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2230.2008.03057.x" "Revista" => array:6 [ "tituloSerie" => "Clin Exp Dermatol" "fecha" => "2009" "volumen" => "34" "paginaInicial" => "e213" "paginaFinal" => "e215" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19120384" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Skin complications of bacillus Calmette-Guérin immunization" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. Bellet" 1 => "N. Prose" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Current Opin Infect Dis" "fecha" => "2005" "volumen" => "18" "paginaInicial" => "97" "paginaFinal" => "100" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lupus vulgaris at the site of BCG vaccination: report of three cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "K. Farsinejad" 1 => "M. Daneshpazhooh" 2 => "H. Sairafi" 3 => "M. Barzegar" 4 => "M. Mortazavizadeh" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2230.2008.03041.x" "Revista" => array:6 [ "tituloSerie" => "Clin Exp Dermatol" "fecha" => "2009" "volumen" => "34" "paginaInicial" => "e167" "paginaFinal" => "e169" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19094126" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/03650596/0000009600000005/v4_202110020832/S0365059621001665/v4_202110020832/en/main.assets" "Apartado" => array:4 [ "identificador" => "82769" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Letter" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/03650596/0000009600000005/v4_202110020832/S0365059621001665/v4_202110020832/en/main.pdf?idApp=UINPBA00008Z&text.app=https://clinics.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059621001665?idApp=UINPBA00008Z" ]
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| 2022 May | 32 | 47 | 79 |
| 2022 April | 69 | 59 | 128 |
| 2022 March | 67 | 73 | 140 |
| 2022 February | 37 | 41 | 78 |
| 2022 January | 84 | 83 | 167 |
| 2021 December | 57 | 50 | 107 |
| 2021 November | 60 | 55 | 115 |
| 2021 October | 78 | 94 | 172 |
| 2021 September | 91 | 79 | 170 |
| 2021 August | 28 | 40 | 68 |
| 2021 July | 4 | 10 | 14 |
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