I66 THE BRITISH J O U R N A L OF TUBERCULOSIS

TUBERCULOUS PULMONARY INFILTRATION AS A SEQUEL TO B.C.G. VACCINATION

BY THEODORE JAMES The Duchess of York Hospital for Babies, Manchester

IN many parts of the world there is propaganda for mass vaccination of susceptible elements of the populations against tuberculous infection. On the other hand, there is a considerable body of opinion firmly opposed to B.C.G. vaccination as the best means to achieve this end.

Complications directly attributable to B.C.G. vaccination may include any of the following: regional lymphadenitis with or without cold abscess formation, erythema nodosum, phlyctenular conjunctivitis and meningitis. Hlouskova and Houstek (I95o) mention three children who developed tuber- culous changes in the lungs at seven-day, two-month and four-month intervals after vaccination. But they do not give details of the kind of tuberculous changes which occurred, and nowhere have I seen a description of pulmonary infiltration as in the case presented here.

Case Report W. D. W., a baby girl aged nine months, was brought to the Out-Patient

Department of the Duchess of York Hospital for Babies. The chief complaint was a large swelling in the left axilla which that morning had discharged spontaneously a yellowish-white material. The father, who was alive and apparently well, had, six years earlier, been diagnosed as a case of active tuberculosis, and, for this reason, a regional Chest Physician had given the baby the protection of B.C.G. vaccination.

This was carried out when the baby was about seven months old. The intradermal technique was used, over the left deltoid region. At no time following the vaccination had the baby shown any constitutional upset although the day before attending the hospital the stools had become loose and the baby had vomited once. The mother was well aware of the reason for the vaccina- tion but the regional swelling and the discharge had rendered her entirely out of sympathy with the purpose of the vaccination. This was her only child.

Physical examination showed a very well nourished, healthy-looking baby, in no distress. The initial vaccination was still in evidence and was proceeding along expected lines, but in the left axilla there was a swelling the size of a hen's egg, which was discharging a yellowish-white material---it was a painless cold abscess of the axillary regional lymph nodes. No cervical lymph nodes were palpable. Clinical examination of the chest revealed no abnormality, but a radiological examination disclosed extensive infiltration of the upper lobe of the left lung and a degree of collapse indicated by the cardiac and mediastinal shift to the side of the lesion (see Fig. I).

Acid-fast bacilli were found in the material from the abscess, but three gastric washings by direct examination and guinea-pig inoculation failed to show the tubercle bacillus. A later swab from the discharging abscess showed polymorphonuclear leucocytes, some lymphocytes, and on culture grew a Staphylococcus aureus, which was sensitive to streptomycin, aureomycin and chloromycetin, but insensitive to penicillin.

P L A T E X X I

Fig. i.--Skiagram showing the infiltration of the left upper lobe.

Fig. 2.--Skiagram showing beginning of re-aeration of left upper lobe.

Fig, 3.--Skiagram showing complete re-aeration of left upper lobe.

To face p. 166

AND DISEASES OF THE CHEST 16 7

Course.--The child continued asymptomatic except for the regional ulcer, which after six months had still not healed completely despite systemic and local streptomycin and para-aminosalicylic acid. Repeated chest X-rays showed no change until six months after the initial examination, when, for the first time, the infiltration of the left upper lobe showed signs of clearing and re-aeration, with a shift of the heart and mediastinum towards their normal positions (see Fig. 2).

At the time of writing--that is, eight months after the first at tendance-- the skiagram of the lungs shows complete resolution (see Fig. 3).

C o m m e n t

This case of pulmonary infiltration, a sequel to B.C.G. vaccination, is exactly comparable with the cases which Martin (I932) included in her clinical group I I I series of tuberculous pulmonary infiltration, as it occurred in the children which she investigated; that is to say, a symptomless infiltration without physical signs was detected on a routine X-ray examination suggested by the local B.C.G. cold abscess formation in the lymph nodes of the axilla, which drained the lymph from the site of vaccination.

The absence of clinical signs in the lungs, the characteristic radiological picture and the course followed were typical of Eliasberg's so-called epi- tuberculosis, a first infection of the lungs by tubercle bacilli. The absence of pulmonary distress and constitutional upset of the least degree excludes other causes for the pulmonary infiltration.

The acuity or absence of symptoms in this type of lung pathology con- tracted by contact with an infective person appears to depend largely upon such variable factors as the dosage, virulence of the infecting bacillus, the frequency of such infection and the nature of the patient's reaction. In the casepresented here, these factors were 0. 5 mg. of B.C.G. introduced on one occasion intradermally in a robust infant, who was anergic to tuberculin. Its significance lies in the involvement of the lymphatic system following infection of the skin, and i n the upper half of the body this involvement may be sufficient to produce the pathological process usually attributable to infection by tubercle bacilli within the respiratory system. It remains, however, uncertain whether this pulmonary complication of B.C.G. vaccination was the result of direct lymphatic spread from the vaccinated arm to the pulmonary lymphatics or indirectly due to pulmonary lodgement of the bacilli after h~ematogenous dissemination throughout the body. By virtue of thefact that B.C.G. vaccina- tion is followed by lymphogenous and h~ematogenous spread both routes of systemic infection appear possible.

REFERENCES HLOUSKOVA, Z. r and HOUSTEK, J. (I 950) : Pediat. Listy, 5, 157" MARTXN, A. (I93~): Am. 07. Dis. Child., 44, 754.