The
BCG Vaccine is routinely administered to Indian newborns at birth along with the hepatitis B and oral polio vaccines. The usual site of administration of BCG is intradermally in the left upper arm.
1 Although BCG is a relatively safe vaccine, there have been certain adverse effects reported with its administration. Most commonly they are local or regional adverse effects including skin ulceration, injection-site abscesses, keloid formation and BCGadenitis.
2 Technical errors in vaccine administration include subcutaneous administration, excessive dose administration and incorrect site of administration, all of which can result in abscess formation.
2
Thigh abscess following incorrect BCG administration has been reported by Namshan et al.
2, and Sedighi et al.
3, in five and three infants respectively. They presented with a slowly progressive, non-tender thigh swelling. The onset was variable ranging from birth to 6 months post-vaccination.
2,3 Three patients additionally had a sudden increase in the size of the swelling within 2 weeks of presentation. No systemic signs or symptoms were reported in any patients. Radiological confirmation was done through either USG or magnetic resonance imaging (MRI).
2,3 Specimen for microbiological testing was obtained either through needle aspiration or incision and drainage. Mycobacterium bovis (the organism from which BCG is derived) was identified from the pus sample in all cases except one, either through culture or polymerase chain reaction (PCR).
2,3 Five patients were treated with 6 months of
Isoniazid and rifampicin, one was treated with 6 months of isoniazid, rifampicin,
Ethambutol and
Clarithromycin and two did not receive ATT. Prognosis was good with all patients showing normal growth and development.
2
The incorrect administration of BCG in the thigh may be due to several possible reasons. The confusion between BCG and
Vitamin K injection, usually administered intramuscularly in the right thigh, or between BCG and hepatitis B vaccine, usually administered intramuscularly in the left thigh, may lead to such an error.
2,3 The use of the same syringe for both BCG and hepatitis B vaccination, may lead to BCG inoculation intramuscularly.
2 Tubercular thigh abscess has also been reported following hepatitis B vaccination.
4,5
In our patients, the absence of the BCG scar on the left upper arm along with MTBC detection on Xpert MTB/RIF assay, which is capable of detecting Mycobacterium bovis
6, is suggestive of a tubercular abscess likely due to incorrect BCG administration in the thigh. We decided to treat our patients as BCG abscess cases. According to the National Tuberculosis Elimination Programme (NTEP) guidelines, BCG abscesses do not warrant treatment and should be allowed to spontaneously regress over weeks to months. If there is suppuration and increase in the swelling size, as in our cases, needle aspiration should be done to prevent rupture and ulceration.
7 If pus is thick, as visualised on USG as thick internal echoes in our cases, excision and drainage should be done. We advised repeat drainage in patient 2 due to refilling, as per NTEP guidelines. Furthermore, NTEP guidelines have found antibiotics and ATT to be ineffective in improving outcomes in BCG abscesses and do not recommend their use.
7 Hence, we did not start our patients on ATT and advised close follow-up instead.
| References : |
- National Health Mission [Internet]. 2018 [cited 2024 Jul 4]. Available from: https://nhm.gov.in/New_Updates_2018/NHM_Components/Immunization/Guildelines_for_immunization/Immunization_Handbook_for_Health_Workers-English.pdf
- Al Namshan M, Oda O, Almaary J, 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 Sep 22;5:472. doi: 10.1186/1752-1947-5-472. PMID: 21939535; PMCID: PMC3189150.
- Sedighi P, Sadrosadat ST, Movahedi M, et al. BCG-Induced cold abscess as a complication of inadvertent vaccine injection: A case series. Clin Case Rep. 2022 Apr 7;10(4):e05711. doi: 10.1002/ccr3.5711. PMID: 35425602; PMCID: PMC8989021.
- Jahan T, Nehvi N, Farooq S. Post-vaccination Tubercular Cold Abscess of Thigh of An Infant. Journal of Microbiology and Infectious Diseases. 2020 Dec 1;10(04):234-6.
- Shah AM, Dash B. Primary Tubercular Abscess of Thigh in Infancy. Indian Pediatr. 2015 Nov;52(11):992. PMID: 26615356.
- Rice JP, Seifert M, Moser KS, et al. Performance of the Xpert MTB/RIF assay for the diagnosis of pulmonary tuberculosis and rifampin resistance in a low-incidence, high-resource setting. PLoS One. 2017 Oct 9;12(10):e0186139. doi: 10.1371/journal.pone.0186139. PMID: 29016684; PMCID: PMC5633176.
- National Health Mission [Internet]. Ministry of Health and Family Welfare ; 2022 [cited 2024 Jul 5]. Available from: https://tbcindia.gov.in/WriteReadData/l892s/9534339438Paediatric_TB_Mangement_Guideline_22082022_V1.pdf
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