Special situations

• BCG disease
• Prevention

BCG disease

Bacille Calmette-Guerin (BCG) is a live, attenuated vaccine and is routinely given to neonates in Malawi, in the right deltoid, in the first week of life. The bacilli originally came from a strain of bovine TB grown for many years in the laboratory. BCG stimulates immunity, increasing the body's defences without itself causing damage. Following BCG vaccination, the body's increased defences will control or kill any TB that enter the body. Most trials in infants in poor countries have shown important protection against disseminated tuberculosis and tuberculous meningitis.

• BCG vaccination may be associated with injection-site abscesses, (suppurative) adenitis, and (very rarely) with disseminated disease.
• HIV- infected infants and other immunodeficient infants are at risk of BCG-related complications.
• Any child <2years who presents with right-sided axillary or regional lymph nodes indicates possible BCG disease and immunocompromised.
• These children require further evaluation.

HIV status unknown?

• Send for VCT.

Are they known to be HIV infected?

• Have they recently commenced ART? If so, then this is likely to be BCG IRIS.

Management

• HIV-uninfected or exposed and thriving and with no other signs of disseminated disease - no drug treatment or management is required. Repeated needle aspiration of a large, fluctuant lymph node may be needed until it spontaneously resolves.
• HIV-infected and otherwise well, refer the patient to the ART clinic and commence on HAART.
• HIV-infected and unwell– febrile, failure to thrive, and/or respiratory signs and symptoms - admit for further investigation and management of possible disseminated BCG disease. These children require four-drug TB treatment with RHZE even though M. Bovis is not sensitive to pyrazinamide since co-infection with M. tuberculosis may occur.

Prevention

In terms of prevention, your most important priority is to diagnose patients with a direct positive sputum smear and to make sure that they complete a standardised treatment. There is a limit to what can be achieved as economic development and interventions to reduce poverty are the most important, however, the following helps.

• Reduce overcrowding wherever possible (which also reduces other infectious
• respiratory diseases, such as pneumonia in infants)
• Improve ventilation of houses.
• Discourage smoking. Smoking increases the risk of tuberculosis

References