Sex: M
Vaccine: BCG
Symptoms: Bacterial test positive, Biopsy skin abnormal, Biopsy soft tissue, Blood culture positive, Bone marrow transplant
Clinical narrative: Disseminated BCG; Information has been received from the authors of a literature, titled as stated below, referring to a 7-month-old infant with with inborn errors of immunity (IEI), homozygous IKBKB gene mutation. Concomitant medication was not reported.  On an unknown date shortly after birth, the patient was vaccinated with bcg live (manufacturer unknown) (reported as BCG vaccine) (route, dose detail, lot number and expiration date were not reported) indication was not reported, however it was defaulted to Tuberculosis bladder.  By 18 days of life, he had suffered from a persistent cough and recurrent rhinovirus infection prompting hospitalization. At 3 months of age, he underwent bronchoscopy for persistent pneumonia, at which time BAL fluid cultures were positive for Streptococcus pneumoniae, Klebsiella oxytoca and Stenotrophomonas maltophila, requiring intravenous antibiotic treatment. He later developed necrotizing pneumonia with Burkholderia cepacia complex and S.maltophila raising concern for an underlying IEI. His initial chest radiograph revealed a left lower lobe con solidation with pleural effusion. His chest computed tomography was significant for a left lower lung consolidation and two nodules in the right upper lung. When this imaging finding was compared to a computed tomography of the chest obtained 2 months prior, the consolidation was noted to be markedly decreased in size. On hospital day 29, a bronchoscopy was performed and BAL fluid specimens were obtained. At 8 months of age (5 weeks into his hospitalization), the boy's mother reported that new, painless skin nodules had developed over the prior month. On examination, the infant had new hyperpigmented nontender skin nodules over his left deltoid, his left posterior shoulder, and his right posterior thigh. The lesions were concerning for disseminated fungal or mycobacterial infection. A Karius plasma mNGS test was sent and positive in 72 hours for MTB complex (369 molecules per milliliter, ref less than 10). This prompted treatment and work-up for disseminated mycobacterial infection. A tissue biopsy was obtained of his right posterior thigh lesion. Histopathologic examination of his skin biopsy revealed granulomatous inflammation. The biopsy was acid-fast bacilli (AFB) smear and culture positive. Gastric and blood cultures were positive for MTB complex 34 weeks after collection, later identified as M bovis-BCG. MTB complex PCR from the skin lesion was positive, but MTB complex PCR testing from blood, gastric aspirates and CSF was negative. The infant was treated with antimycobacterial therapy for a total of 14 months following engraftment. He was doing well clinically and continues to follow-up with the bone marrow transplant team for post-transplant care.  The reporter considered the event to related to the bcg live (manufacturer unknown).  Upon internal review, the event Disseminated BCG was considered to be medically significant.    A copy of the published article is attached as further documentation of the patient's experience.