Case Series of HIV-infected children with Bacillus

Calmette-Guérin Vaccine Related Lymphadenopathy in

Lilongwe, Malawi

John Midturi

Kazembe, PN., Schutze, GE., Kline, MW

Background-Malawi

Population of 13 million HIV prevalence 14%

(15-49yr) 30,000 children infected

with HIV 125,000 individuals

have been started on ART (Sept 2007) children 8%

Background-Malawi (2)

BCG incorporated into EPI schedule in 1974 Administered within 1st week of life 99% coverage Danish 1331

Background-Baylor COE Baylor COE- established officially in

November 2006 Provision of pediatric HIV care, treatment

and training 3612 patients

2155 active patients ~50% on ART

Enroll ~100 new clients/month Average age at enrolment

4.56 years

Background-BCG vaccine Live attenuated vaccine Adverse reactions

Injection site ulceration Lymphadenitis Disseminated disease Dependent on strain, administration

method, bacillary load, host immunity, and physical-chemical property

Incidence 0-17%

Adverse reactions to BCG in HIV infected infants

True Incidence, unknown: Under-reported 0% to 30% Frequency similar to uninfected

population Turnbull CID 2002

HIV-negative: 2.5% vaccine site abscess & 1.7% lymphadenitis

HIV-Infected: 2.7% vaccine site abscess & 0.7% lymphadenitis

Objective

Identify incidence of BCG Disease in children infected with HIV at Baylor COE

Determine clinical course of BCG disease

Methods

Retrospective chart review July 2005 through February 28th, 2007 All children diagnosed as HIV-infected at

the Baylor COE.

Data gathering: Computerized medical record chart Diagnosis of axillary lymphadenopathy,

axillary lymphadenitis, BCG reaction, TB lymphadenitis, or right axillary adenopathy

Methods

Diagnosis: BCG disease (EPI):

ipsilateral axillary lymph node enlargement of >15x15 mm, suppurative ipsilateral axillary lymphadenitis, injection site abscess of 10 mm, or a clinically significant or non-resolving BCG papule

BCG disease IRIS: Temporal association of ARV initiation and

development of right axillary adenopathy CD4/CD4% increase >5%

Results 13 cases:13/958, prevalence of 1.46% in HIV-

infected children 10 BCG Disease IRIS (1.04%)

Age: Range 4 months to 18 months Median 9 months

WHO Stage: 8 Stage III (PTB/thrush/diarrhea) 5 Stage IV (PCP/severe malnutrition)

Follow-up time: Range 2 weeks to 37 weeks Median 20 weeks

Median CD4% 13%, (2.2%-23.4%)

0 2 4 6 8 10 12

123456789

10111213

Weeks

Patient

Time to Onset of BCG Disease IRIS

Median 3.5 weeks, (1-11weeks)

69.2% Spontaneously rupturedMedian time to rupture 9.2 weeks, (2-14 weeks)

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5

123456789

10111213

Months

Patie

nt

Time to resolution

Median 3 months, (1-4 months)

Management Treatments:

8 TB therapy, 6 started TB meds prior to BCG Disease

6 antibiotics All Started ART No surgical intervention

Outcome: 11 alive 2 died

both had BCG disease prior to ART 1 on TB therapy

Mortality 3.2 per 100 weeks follow-up

Conclusions Prevalence of 1.46% in our HIV-infected

pediatric population Most develop BCG Disease IRIS 3-4

weeks after ART ~70% of them rupture 9 weeks after

ART Most cases resolved after 3 months Most of our patients were already on TB

therapy when they developed BCG Disease

Future Complete analysis of our data Potentially will become a more significant

issue with the proposed universal treatment for all HIV-positive children under 12 months of age

Prospective study: Role of INH prophylaxis to see if it

decreases incidence of BCG disease Delaying BCG vaccination in HIV-infected

infants

Acknowledgments

Dr. Peter Kazembe BIPAI Dr. Mark Kline Dr. Gordon Schutze Dr. Mark Kabue All the patients and families from the

Baylor COE-Malawi