Usefulness of echocardiography for papular tuberculid with fever after BCG vaccination

Description

A male infant developed a papular rash at the BCG vaccination site 4 weeks after BCG vaccination. He had been born at 33 weeks 5 days of gestation, weighing 2009 g. He had a history of atopic dermatitis. The day after its appearance, the papular rash spread to the whole body, and the patient presented to our department. On presentation, the skin rash was distributed over the entire body, including the face, and was particularly obvious around the BCG vaccination site (figure 1A,B). The QuantiFERON-TB Gold Plus assay and antibody titre tests for measles and rubella were negative. Three days later, a fever appeared and the papular rash worsened. Because of rash and fever are principal clinical features of Kawasaki disease (KD), we performed echocardiography and found no abnormalities in the coronary arteries or myocardium. A skin biopsy of a fresh papule on the left upper arm was performed to differentiate the lesion from tuberculosis. The fever resolved within 2 days, and no further principal clinical features of KD appeared. Histopathological findings of the skin biopsy showed no Langhans giant cells (figure 1C), and Ziehl-Neelsen staining was negative. Lymphocytes and histiocytes infiltrated the shallow to deep layers of the dermis, gathering around blood vessels and appendages such as sweat glands (figure 1D). Based on the blood test results, histopathological findings and medical history, a diagnosis of generalised papular tuberculid was made. The skin rash improved during outpatient follow-up. No new lesions appeared within 2 weeks of onset, and the rash showed a tendency to fade with mild pigmentation within 1 month after onset without treatment.

Figure 1.

(A, B) Generalised papular tuberculid. (A) Vaccination site on the left upper limb and face. (B) Left outer thigh. (C, D) Pathological findings. (C) H&E-stained image. Bar=200 μm. Examination revealed infiltration of lymphocytes and histiocytes around blood vessels and appendages such as sweat glands in the shallow to deep layers of the dermis. Plasma cells, eosinophils and neutrophils were inconspicuous. (D) Staining with CD68 (KP-1), a histiocyte marker. Bar=500 μm. CD68-positive cells clustered around blood vessels and appendages.

Skin lesions are among the most common adverse reactions after BCG vaccination, second to lymphadenitis.¹ Because the development of skin lesions with fever after BCG vaccination is not rare,² KD should be considered a differential diagnosis in such cases. The sixth edition of the Japanese diagnostic guidelines for KD was revised in 2019 to include skin rash after BCG vaccination as a principal sign.³ Redness and crust formation at the BCG vaccination site are useful diagnostic signs of KD and are seen in >70% of patients with KD between 3 and 20 months of age.⁴ Papular tuberculid may also be combined with KD.⁵ To our knowledge, few reports have focused on the consideration of KD, as in our case, let alone tuberculosis. There is no established procedure for the treatment of generalised papular tuberculid after BCG vaccination because the disease is not yet well recognised. Therefore, it is important for clinicians and trainees to perform echocardiography when KD is suspected in patients who develop papular tuberculid with fever after BCG vaccination.

In conclusion, we encountered a case of papular tuberculid with fever after BCG vaccination diagnosed by appropriate medical procedures. We emphasise the usefulness of echocardiography as a less invasive test when KD is suspected in cases such as ours.

Are your conclusions supported by the clinical information described and illustrated? Yes.

Patient’s perspective.

(from his mother)

The first symptom I noticed was a skin rash on his left arm where he had been inoculated with BCG. I thought it would clear up soon, but the next day I was surprised to find that the rash had spread over his entire body. He was in a good mood and his feeding volume was the same. The rash did not appear to be itchy.

Learning points.

• Echocardiography is useful for investigation of Kawasaki disease (KD) in patients who develop skin lesions with fever after BCG vaccination.

• Redness and crust formation at the BCG vaccination site are useful diagnostic signs of KD.

• One of the most common adverse reactions after BCG immunisation is the development of skin lesions (including cutaneous tuberculosis), ranking second in frequency to lymphadenitis suppurativa.

Ethics statements

Patient consent for publication

Consent obtained directly from patient(s).