Bacille Calmette-Guérin-responsive lymphadenitis
Basic definition: Lymphadenitis that occurs 1-8 months after BCG vaccination or oral administration to newborn infants. The axillary lymph nodes on the injection side are enlarged in shoulder vaccinees, and a few involve the supraclavicular lymph nodes. In oral vaccinees, it mostly occurs in the deep cervical lymph nodes. There is usually no systemic symptom, and it gradually absorbs on its own. In a few cases, it may liquefy and ulcerate. Anti-tuberculosis drugs are not required. It can be treated locally. Liu Zhenyong, Department of Pediatric Surgery, Yangzhou First People’s Hospital
Pathological diagnosis based on.
1.No history of contact with tuberculosis, regional lymphadenopathy occurred shortly after vaccination, which is consistent with primary infection;
2, no symptoms of tuberculosis poisoning and other parts of tuberculosis, the child has good growth and development;
3.Mycobacterium tuberculosis is not easily detected by smear of lymph node puncture, and the general bacterial culture is negative;
4.The lesions are mainly multinucleated giant cells or Langhans giant cells, and caseous changes are rare.
Clinical discussion and analysis.
Only 1% can cause enlargement of axillary or supraclavicular lymph nodes, and about 1% of children have lymph node rupture, which may be related to the low immune function of individual infants. Treatment of septicemia: Since infants are troublesome to feed, chemotherapy is given twice a week with HL to reduce the number of doses and to make it easier to use. The HL program is basically free of follow-ups after one outpatient treatment. In some cases, the swollen lymph nodes in the axilla have almost disappeared, and they come to the clinic to ask whether they need further chemotherapy. The high efficacy of BCG vaccination is due to the fact that BCG vaccinated infants are basically drug-free at first treatment and therefore have a high efficacy.
The causes of lymph node enlargement due to BCG vaccination are related to the virulence of the vaccine, the number of live bacteria, the vaccination technique and individual differences. In the examination of newborns with swollen lymph nodes caused by BCG vaccination, the local reaction to the vaccination was normal, and the formation of card marks was good, indicating that it was not caused by overdose or deep vaccination. However, the strong positive reaction of PPD test may be caused by uneven dilution of the vaccine, failure to shake well when injecting, overdose reaction caused by accumulation of the vaccine, or it may be caused by abnormal autoimmune status.
BCG vaccination and treatment of vaccination reactions
BCG vaccine is one of the vaccines planned for immunization of children in China. It is the only vaccine that can produce local ulcers among the vaccines currently administered, and it is also the vaccine with more vaccination reactions at present. In recent years, tuberculosis prevention and control personnel as well as those who implement planned immunization do not know enough about BCG vaccine and its vaccination, so once a BCG vaccination reaction occurs, they are often at a loss and give wrong diagnosis and treatment, causing adverse effects to the vaccination recipients, and some even cause social panic, which seriously affects the development of BCG vaccination work. The following is a brief introduction of BCG vaccine for the reference of colleagues.
I. Characteristics of BCG vaccine
BCG is the abbreviation of Bacillus Calmette Guerin, abbreviated as BCG is short for Bacillus Calmette Guerin. BCG vaccination can make the body develop specific immunity to the tuberculosis bacillus, and is used to prevent tuberculosis.
II. Immune response to BCG vaccination
Immunity to tuberculosis is cellular immunity. After BCG vaccination, T lymphocytes are sensitized in the body. When TB bacilli invade the body, these sensitized T lymphocytes release a large number of lymphokines (macrophage chemotactic factor, macrophage inhibitory mobile factor, macrophage activating factor, etc.), which activate macrophages and increase their phagocytic ability, and finally engulf and digest TB bacilli. It has been suggested that the material basis for the production of protective immunity in the organism is the nucleic acid of M. tuberculosis, and the material basis for the production of metabolic reactions is mainly lipids (waxy D, etc.). Tuberculosis protein can make the body produce humoral immunity against tuberculosis antibody, but the cell membrane of tuberculosis bacillus is protected by waxy substance, so the antibody cannot attach to the surface of bacteria to produce immune response and cannot kill tuberculosis bacillus.
III. Target of vaccination
When the annual infection rate > 1% —- newborns for general vaccination. At present, the target of vaccination for planned immunization in China is newborns.
The annual infection rate <0.2% - the initial vaccination is postponed to the time of elementary school entrance.
IV. Vaccination techniques
Vaccination personnel: personnel who must be trained.
Vaccination equipment: 1 ml syringe, 4.5 needle.
Inoculation site: 0.5 cm of the lower outer edge of the deltoid muscle of the left upper arm.
Inoculation method: Intradermal inoculation.
Inoculation dose: 0.05-0.1 mg/0.1 ml.
V. Contraindications to vaccination
Fever, weight less than 2,500 grams, persistent vomiting, dyspepsia, rash, pyoderma, eczema, pathological jaundice, trauma during delivery, congenital malformation.
VI. Vaccination reactions and treatment
(A) Normal reaction to vaccination
1.Normal reactions
(1) Systemic reactions: Some children vaccinated with BCG vaccine can develop fever, between 37.5℃-38.6℃. In addition to the rise in body temperature, some vaccinees may have headache, dizziness, chills, weakness and general discomfort, which usually last 1-2 days.
(2) Local reaction: time of appearance: 10-15 days for the first planting; 2-3 days for the second planting. Reaction process: redness, swelling, pustules, ulcers, crusts, scars; a few children, especially newborns, may have swollen lymph nodes in the axilla, neck or clavicle on the same side of vaccination. However, local reactions to vaccination or enlarged lymph nodes do not exceed 1 cm. The period from redness and swelling to scar formation is usually 1-3 months, and does not exceed 6 months.
2. Strong reaction
Local redness and hard nodes or lymph nodes in the axilla, neck or supraclavicular area on the same side of the vaccination are larger than 1 cm; the healing time is larger than 6 months, and the occurrence of any of the above conditions is a strong reaction to BCG vaccination. Manifestations of strong reactions.
(1) Local reaction to vaccination: blisters, pus blisters, deep pustules, granulation tissue proliferation, and
(2) Lymphadenitis: lymph nodes larger than 1 cm, some may produce abscesses and ulcers.
3.Treatment
(1) The local reaction of BCG vaccine should not be applied hot. For people with special sensitivities, small doses of analgesic and antipyretic drugs can be considered, usually 2-3 times a day for 1-2 days.
(2) Local treatment: Keeping the local area clean can generally be cured without special treatment.
Small blisters: complex iodine disinfection.
Large blisters: syringe to draw pus, if necessary 5%-10% isoniazid ointment, rifampicin topical application.
Ulcers: local disinfection, 10% isoniazid ointment, rifampicin applied externally with petroleum jelly gauze.
Deep abscesses (including lymph node abscesses): when there is fluctuation, pus is drawn with sterile empty needle, flushed with saline, injected with streptomycin and isoniazid solution for retention, once a week. For deep abscesses, it is best to treat with incision and drainage of pus, see “Treatment of reactions to overdose and subcutaneous inoculation” for details.
Granulation tissue hyperplasia: cut flat with sterile scissors.
(ii) Reactions to overdose and subcutaneous vaccination
Overdose means that the amount of BCG vaccination exceeds the normal amount of vaccination, and subcutaneous vaccination means that the prescribed intradermal BCG vaccination is injected subcutaneously or intramuscularly. This is caused by technical errors or errors of responsibility in BCG vaccination work.
1.Main manifestations
(1) Fever: Most of them are 37.5-38.50C, and a few of them have high fever. 1981, Chu Qi (163 Hospital) reported that 263 children were given BCG vaccine for tuberculin test, and 260 of them had fever. In 1984, Zhang Wuqian (Xiangxiang County People’s Hospital) reported 397 cases of subcutaneous or intramuscular injection of BCG vaccine on the skin and 90 children (22.7%) had a body temperature of 37.6C or more. Generally between 16%-60%.
(2) Some children may have the following symptoms: malaise, poor mental health, irritability, night sweats, abdominal pain, intermittent arthralgia, wasting, and loss of appetite.
(3) Local reactions to vaccination.
Local redness and swelling of inoculation, deep abscesses, ulcers, granulation tissue proliferation, etc.
Lymphadenitis: swelling of lymph nodes, some may produce abscess and ulceration.
2. Treatment.
(1) Promptly report.
(2) Within 72 hours, closure therapy: procaine 2-4ml + isoniazid 50mg, fan closure, once daily.
(3) Anti-TB treatment: 10mg/day per kg body weight.
(4) Local ulcerative abscess and lymph node enlargement, treated as strong reaction.
(5) Surgical treatment: For local abscesses or lymph nodes that have produced abscesses, surgical treatment can greatly shorten the course of treatment. Method of surgical treatment: After local anesthesia, the skin and granuloma wall are cut longitudinally, and the granulation tissue and necrotic tissue under the skin and at the base are gently scraped out with a papillary scraper, keeping the uncolored skin as much as possible, and if the skin has become purple and necrotic, it is cut off and trimmed. And probe with a metal probe, if there is deep fistula likewise scrape off the granulation tissue; flush with 5% isoniazid.
3. Prognosis: Zhang Zhiang et al. of Chongming County Tuberculosis Control Institute in Shanghai reported (China Anti-TB Newsletter, 1982, 1: 35) that 96 cases of intradermal BCG were subcutaneously inoculated in March 1980, 43 cases had localized cold pustules, and 36 cases were treated with surgical debridement.
Treatment results: healing was rapid after surgical debridement: 5 days at the earliest. The latest was 18 days. The average was 10.6 days.
(iii) Pulmonary reactions.
1, the lung reaction of normal vaccination BCG vaccination, the vaccine can quickly reach the lymph nodes from the inoculation site through the lymphatic vessels, and even the whole body. Therefore, for a period of time after BCG vaccination, some people may have swollen lymph nodes in the axilla and other places; some people may even have swollen bronchial lymph nodes and mediastinal lymph nodes in the lungs and increased vascular shadows around the hilum. Normal BCG vaccination caused 0.34% enlargement of lymph nodes in the hilum of the lung (Diao Youdao et al.) Hunan reported lung reactions in 120 cases of normal vaccination with positive nodulin test for BCG vaccination, 2 cases (1.6%) showed new foci of tuberculosis. Inflammatory lesions appeared in 2 cases, accounting for 1.6%.
2. The manifestation of the lungs of over-vaccination
In 1987, Chen Fuchu reported the occurrence of pulmonary abnormalities in 55 cases of over-vaccination
Vaccination time: April 1980. Inoculation dose: 0.658mg/person. Site of inoculation: 1-2 cm above the wrist on the palm side of the left forearm. number of inoculations: 55. All cases were observed by film taking 3 times within 7 months.
3. Causes of pulmonary reactions
Pulmonary texture and structural changes in the lungs were caused by reactive lymphangitis or congestive reactions in the interstitial or hilar regions of the lungs after BCG entered the blood circulation system. Pulmonary hilar nodules are due to a reactive enlargement caused by the entry of BCG into the lymphatic system. Therefore, lymph node reaction caused by BCG vaccination cannot be diagnosed as tuberculosis because there is an essential difference between the case changes caused by BCG vaccination and those caused by Mycobacterium tuberculosis, and the pathological changes caused by the former are benign and degenerative, and can dissipate naturally without leaving traces.
4. Prognosis of pulmonary reactions: Pulmonary reactions can heal with the healing of local reactions to vaccination.
(iv) Systemic BCG infection
Systemic infection of BCG vaccination is a serious complication. For example, patients with congenital thymus defects or hypoplasia are prone to BCG vaccination systemic infection. The main manifestations are similar to blood-borne tuberculosis-like changes after BCG vaccination, no thymus shadow or smaller than normal thymus shadow on X-ray, low absolute value of T-lymphocytes, antacid staining of lesions that reveals antacid bacilli, and unsatisfactory effect of antituberculosis treatment, most of which die due to BCG transmission or other infectious diseases.
(v) Other reactions.
Induction of silver skull, local keloid, allergic purpura, anaphylaxis, group hysteria, etc. For details, please refer to the relevant information, which is omitted here.
(6) Definition of abnormal reactions to vaccination
Abnormal reactions to vaccination are adverse drug reactions that cause damage to the tissues, organs and functions of the vaccine recipient’s body during or after the implementation of standard vaccination, and all parties concerned are not at fault. The following cases are not abnormal reactions to vaccination.
1. general reactions after vaccination caused by the characteristics of the vaccine itself.
2. Damage caused to the vaccine recipient due to unqualified quality of the vaccine.
3. Damage caused to the vaccinees by the vaccination unit in violation of the vaccination practice, immunization procedures, vaccine use guidelines and vaccination programs.
4. the recipient is in the incubation period or prodromal period of a disease at the time of vaccination and has incidental morbidity after vaccination
5. the recipient has contraindications to vaccination as specified in the vaccination instructions, and the recipient or his guardian does not truthfully provide the recipient’s health status and contraindications to vaccination before vaccination, and the recipient’s original disease acutely recurs or worsens after vaccination.
6. Psychogenic reactions of individuals or groups due to psychological factors.
BCG vaccination is a kind of attenuated, live bovine Mycobacterium tuberculosis.
The purpose of BCG vaccination is to produce immunity and protect the inoculated person from infection and disease of the tuberculosis bacillus. After more than 70 years of vaccination, it is believed that BCG vaccination has a good immune effect on the prevention of tuberculous meningitis and cornual tuberculosis, with a protection of 65%-95%. In contrast, the preventive effect against tuberculosis, especially in adults, is very limited.
BCG vaccination has been administered for more than half a century and the number of vaccinated people has exceeded 4 billion, but so far no country or region has controlled or eliminated tuberculosis, and even the incidence of tuberculosis in some countries or regions is still on the rise. Animal experiments have proved that BCG vaccination can effectively prevent the spread of TB bacilli from the primary foci in the lungs to other organs such as the liver and spleen, and its effect may be to reduce the recurrence and spread of endogenous TB bacilli, but it cannot prevent the reinfection and development of exogenous TB bacilli. Therefore BCG is not a vaccine with as high a preventive effect against tuberculosis as smallpox, polio, and poliomyelitis vaccines. However, in countries or regions with high epidemic of tuberculosis, BCG vaccine still has certain preventive effect on tuberculosis, especially on tuberculous meningitis and cornual tuberculosis which have high risk to children’s health and life, so BCG vaccination is still one of the measures to prevent and control tuberculosis in countries or regions with high epidemic of tuberculosis.
VIII. Progress of research on new vaccines for tuberculosis prevention
There are three aspects of current research on new vaccines for tuberculosis prevention.
1.Live vaccine
So far, only live attenuated tuberculosis vaccine with nutrient deficiency has shown comparable or even stronger immune protection than BCG vaccine in animal experiments, but the reversion mutation rate of this vaccine is still relatively high and its safety is a concern. At present, we are also studying the construction of dual nutrition-deficient live attenuated tuberculosis vaccine, but it is technically difficult to succeed in the short term.
2.Dead vaccine
Studies have found that non-tuberculous mycobacteria (M, vacce) into the high-temperature fire after the bacterium can prevent leprosy, and can even improve the cellular immunity of AIDS patients to control the deterioration of AIDS. At present, in Africa is being carried out M, vacce dead bacterium vaccine to prevent tuberculosis research.
3.Gene vaccine
DNA vaccine expressed in vivo Mycobacterium tuberculosis protein can bind to class I molecules of MHC, which can induce cellular immunity-based immune response, therefore, DNA vaccine should have strong immune protection against intracellular parasitic Mycobacterium tuberculosis. However, the study was short, and the exact mechanism of its induced immune response and the immune effect in human remains to be further investigated.