No abstract

The pathologic findings from biopsy specimens from 9 patients with postvaccination bacille Calmette-Guérin (BCG) infection are presented. The patients were vaccinated with BCG during the first 2 days of life. Four patients had normal immunity and 5 patients were immunocompromised. The pathologic findings in both groups were different. Biopsy specimens from patients with normal immunity showed multiple epithelioid granulomas and Langhans giant cells with or without suppuration. Caseous necrosis was minimal. Ziehl-Neelsen stain for acid-fast bacilli showed a few bacilli in 2 cases and was negative in the remaining 2 cases. Biopsy specimens from the second group of patients, who were immunosuppressed, consisted mainly of skin and subcutaneous tissue. These revealed diffuse infiltrates of histiocytes with plump nuclei and abundant "dirty" grayish cytoplasm, which was full of numerous acid-fast bacilli. The clinical course for the 2 groups also was different. Patients with normal immunity generally recover completely, spontaneously or after excision of the suppurative lymph node and usually do not require antibiotic chemotherapy. In immunosuppressed patients, disseminated BCG infection, which may prove fatal, may develop. These patients should receive a full course of antituberculous chemotherapy and, in addition, treatment of the underlying immunologic disorder.

Nine patients with primary immunodeficiency who received bacillus Calmette-Guerin (BCG) vaccine at birth developed disseminated BCG lesions and presented clinically with generalized skin rash and skin nodules. Fine-needle aspiration biopsy of the skin nodules and/or enlarged lymph nodes was performed in all patients. The most common cytologic pattern encountered was cellular smears showing a large number of histiocytes with abundant streaked cytoplasm in a background of neutrophils and debris. No granulomas were noted. Ziehl-Neelsen (ZN) stain for acid-fast bacilli showed a large number of these bacilli within the cytoplasm of the histiocytes, and extracellularly. This pattern was seen in 6 patients. The cytologic smears from 3 patients showed epithelioid granulomas in a background of neutrophils and debris. ZN stain for acid-fast bacilli showed fewer numbers of these bacilli compared to the first cytologic pattern. In conclusion, the most common cytologic pattern of postvaccinial disseminated BCG lesions in immunocompromised patients is a large number of histiocytes with abundant streaked cytoplasm in a background of neutrophils and debris. No epithelioid granulomas are seen in this pattern. A less frequent pattern is also encountered which shows epithelioid granuloma in a neutrophilic background. In both cytologic patterns, ZN stain for acid-fast bacilli is positive. However, in the first and most common pattern, the number of acid-fast bacilli is much larger than that seen in the second pattern. The different cytologic patterns might be related to the status of immunity of patients at the time of biopsy.