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Bacille Calmette-Guerin Vaccine-Induced Disease in Children with HIV/AIDS
HAIVNHarvard Medical School AIDS
Initiatives in Vietnam
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Learning Objectives
By the end of this session, participants should be able to:
Recognize clinical signs/symptoms suspicious for BCG disease in HIV-infected children
Identify different forms of BCG-related complications in HIV-infected children
Propose the appropriate work-ups and treatment for BCG
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BCG Vaccine: Overview (1)
M. bovis is part of the Mycobacterium tuberculosis complex
BCG (bacille Calmette-Guérin) is:• a live attenuated strain of M. bovis, developed as a
vaccine against TB disease • inherently resistant to PZA and may be resistant to INH
In TB-endemic countries including Vietnam, BCG is given at birth or shortly thereafter:• Although BCG does not provide 100% protection against
TB, it does reduce the risk of severe disease, namely meningeal and miliary TB, in children
The rate of adverse effects due to the vaccine:• Before HIV: 0.19-2 cases/million vaccinated infants
BCG Vaccine: Overview (2)
Prompt treatment with both anti-mycobacterial and ARV therapies increases chance of survival
Healthy infants and children usually only develop:
injection site ulcerationor lymphadenitis
Because BCG is a live attenuated vaccine, it can cause disease in susceptible individuals:
• HIV infected infants are at a much greater risk of BCG related complications
• Disseminated disease:only occurs in severely
immunocompromised individuals, and
carries an extremely high mortality rate above 80%
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BCG Vaccine Recommendation
Give BCG vaccine to all HIV-exposed children
Postpone vaccination until HIV infection is excluded in the following situations:• High risk of HIV infection: mother and infant
did not receive PMTCT, or• The infant presents with signs or symptoms
suggestive of HIV infection, or• Low birth weight (under 2500 g) and pre-
termed infants
BCG-related Complications
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Suppurative Axillary Lymphadenitis (Regional Disease)
Ipsilateral to vaccine injection site Can become extremely inflamed and
painful Take several months to subside Needle drainage or lymph node excision
may be necessary If there are signs of dissemination, anti-
TB treatment recommended
Left Axillary Lymphadenitis
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Disseminated BCG Disease
Usually in young children with advanced HIV
Median age at onset is 8 months Most common signs/symptoms:
• Wasting, failure to thrive• Anemia, usually severe• Hepatosplenomegaly• Axillary, cervical adenitis• Osteomyelitis• Infiltrates on CXR
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Extensive bilateral infiltrates in a patient with disseminated BCG
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Work-up
Any child with left axillary lymph node adenitis:• CBC, AST/ALT, CD4• CXR• Gastric aspirate, needle aspiration of
lymph node: send for AFB stain and culture with strain
identification, drug susceptibility
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Treatment (1)
Local or regional disease:• RHE• PZA for 2 months or until TB excluded• Needle aspiration or FNA if node
fluctuant• Consider LN excision• Start ART
Treatment (2)
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Case Study
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Case Study (1)
3 year-old boy, HIV+, presented with:• A left axillary lymph node and a left
cervical LN• Also hepatosplenomegaly
What do you want to do about the lymph nodes?
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Case Study (2)
Aspiration of lymph node was positive for AFB
Do you want to do anything further with the aspirates?
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Case Study (3)
Patient was placed on TB therapy with 2RHZ/4RH
CD4 3 cells/mm3 Started on AZT/3TC/EFV Over the next 3 months, a lymph node
drained and healed, and some other lymph nodes came up in the axilla. New lymph nodes appeared in cervical and supraclavicular areas
What do you think is going on?
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Case Study (4)
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Case Study (5)
After 3 months of ART, CD4 increased from 3 to 8 cells/mm3, no weight gain
What do you want to do? Given poor clinical progression, he was
switched to second line with LPV/r + 3TC + TDF
6 months after, all LN resolved.
Case Study (6)
After 3 months on TB therapy and ARV
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Key Points
BCG can cause severe complications in HIV-infected children
BCG vaccine should not be given to infants at high risk of HIV infection or symptomatic infants
Anti-TB treatment and ARV should be started promptly for disseminated disease to improve chance of survival
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Thank you!
Questions?