Pressure-related complication? :Bacillus Calmette-Guérin (BCG)-induced skin granuloma in a Japanese infant

A 5-month-old girl with no significant medical history, including at birth, received Bacillus Calmette–Guérin (BCG) vaccination on the left upper arm. Seven weeks following vaccination, an elevated mass 1.0 cm in diameter appeared at a site 2 cm medial to the vaccination area (Fig. 1). Because no signs of inflammation or pain were observed, the mass was followed monthly in the outpatient clinic. Puncture drainage and excision of the mass was performed at 18 months of age because it gradually increased in size with redness. No mycobacteria were observed on cytologic examination of the drainage fluid; however, polymerase chain reaction for Mycobacterium was positive. Histopathology revealed epithelioid cell granulomas accompanied by Langhans giant cells and enclosing caseating necrosis, consistent with BCG-associated epithelioid granuloma (Fig. 2). The infant had no family history of tuberculosis, her chest radiographs were normal, and no other skin lesions were observed. Results of laboratory tests, including interferon-gamma release, neutrophil function, and lymphocyte subset were unremarkable. Following mass excision, isoniazid therapy was started for 5 months because the healing process was initially slow. Gradual improvement, without granuloma recurrence, was observed as the treatment continued.Figure 2Histopathology of the skin lesion. Epithelioid cell granulomas, Langhans giant cells, and areas of caseating necrosis. A. Low magnification. B. High magnification.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Solitary tuberculosis-like granulomas of the skin near the BCG vaccination site have been rarely reported.1Kigawa T. Kawai M. Yamaoka H. Kondoh A. Tojo M. Mabuchi T. Two cases of subcutaneous tuberculous granuloma associated with BCG vaccination.Tokai J Exp Clin Med. 2020; 45: 136-138PubMed Google Scholar In Japan, a plastic cylinder apparatus implanted with nine fine short needles has been used for BCG vaccination to ensure that the needle tips stay intradermal, preventing them from reaching the subcutaneous space.2Yamamoto S. Yamamoto T. Historical review of BCG vaccine in Japan.Jpn J Infect Dis. 2007; 60: 331-336Crossref PubMed Google Scholar Some authorities suggest that these lesions may result from pressing too hard against the infant's arm, which may cause subcutaneous administration.3Vaccinations Center at Meitetsu Hospital. Reasons for not applying hard pressure with the Japanese BCG Needle Device. Available at https://www.meitetsu-hospital.jp/app/wp-content/uploads/2019/12/yobou_198-1.pdf. Accessed December 1, 2023.Google Scholar Although the precise mechanism of these cutaneous lesions cannot be explained by lymphatic flow, as in BCG lymphadenitis, the pressing force applied when using a multineedle device should be considered. The authors did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.