Age: 1.0
Sex: M
Vaccine: HEPA, MMR, VARCEL
Symptoms: Inflammation, Joint swelling, Lymphocyte count normal, Mucous stools, Mycobacterium tuberculosis complex test positive
Clinical narrative: Initial unsolicited report received from the literature on 16-AUG-2016. This case is linked to: 2016SA155328 (cluster case). The following is verbatim from the article: Abstract: Most cases of osteomyelitis in children are caused by Staphylococcus aureus, although Kingella kingae, various streptococci, and Salmonella species also underlie this condition. Organisms such as Mycobacterium, Histoplasma, and Cryptococcus are much less commonly identified as etiologic agents in osteomyelitis. This case report describes a 16-month-old boy who had extensive inflammation of and discharge from his right ankle. Imaging studies supported a diagnosis of osteomyelitis. Acid-fast bacillus (AFB) and routine wound cultures were ordered on the wound discharge. The AFB culture yielded a positive result for Mycobacterium bovis, and molecular diagnostic testing further genotyped the microorganism as Mycobacterium bovis, Bacillus Calmette-Guerin (BCG). Herein, we report a rare case of osteomyelitis that we believe resulted from a BCG vaccine that the patient had received. This case involves a 16-month-old male patient who was vaccinated with a dose of PENTACEL; PNEUMOCOCCAL VACCINE, ROTAVIRUS VACCINE and BCG VACCINE at the age of 6 months; HEPATITIS B VACCINE at the age of 4 months; MEASLES, MEASLES-MUMPS-RUBELLA, HEPATITIS A VACCINE, VARICELLA VACCINE at the age of 12 months (for all the vaccines batch number, expiry date, dose, dose in series, route and site of administration were not reported). It was reported that the patient received a previous dose of PENTACEL, PNEUMOCOCCAL VACCINE and ROTAVIRUS VACCINE at age of 2 months and 4 months; HEPATITIS B VACCINE at birth and at the age of 2 months. Patient had a medical history of enteritis. Concomitant medications were not reported. On an unspecified date, following the vaccination, the patient had diarrhea, abdominal pain, mucous-laced stools, patient had not borne any weight on his right leg, fever and ankle abscess, septic arthritis, mild swelling and tenderness of his right ankle along with discharge from, putative bacterial infection and the associated pain and inflammation, ankle symptoms had worsened, accelerating redness, pain, and swelling of his right ankle, the center of the proximal aspect of the talus was eroded, an abnormal hazy opacity around the talus indicated calcifications of associated soft tissue in this area and osteomyelitis. The patient visited to the emergency department. On an unspecified date, the patient was hospitalized. Lab data included on an unspecified date, complete blood count: WBC 18.0x 103/microliter, lymphocyte and neutrophil counts being within 2% (normal). It was reported a tuberculin skin test was performed on his admission to the hospital. Routine stool and blood cultures, as well as several serological tests, including Coccidioides antibodies (immunoglobulin and IgM), Entamoeba histolytica antibodies, and Quanti FERON TB Gold were ordered. Routine bacterial, acid-fast bacteria (AFB) and fungal cultures on the 2 to 3 mL of purulent aspirate, the aspirate was also analyzed for the presence of kingae DNA by polymerase chain re-action (PCR). The TB skintest yielded negative results with a 16 mm x 13mm area of induration. The routine wound, stool, and blood cultures all yielded negative results. For the presence of pathogenic microorganisms as did the tests kingae DNA by PCR, serological tests, and fungal cultures. A chest X-ray that we ordered after the positive TB skin test result also yielded a negative result. The Quanti FERON TB Gold test results were negative, but the AFB culture performed on the purulent wound aspirate yielded positive results for Mycobacterium bovis. The cultures had eventually yielded negative results. Magnetic resonance imaging revealed extensive edema involving the calcaneus, talus, and distal tibial metaphysis, with a large amount of fluid collection along the lateral Side of the ankle that appeared to originate from the talus. The synovial spaces were markedly thickened, w1th rim enhancement of the central aspect of the talus that reflected an intraosseous abscess or tissue necrosis. The talus exhibited central liquifactive necrosis that had erupted through the lateral cortex; the distal tibia and calcaneus showed no liquifactive changes. This collection of findings was compatible with an impression of extensive osteomyelitis involving the talus and low-grade osteomyelitis of the tibia and calcaneus. The patient received corrective treatment with intravenous (IV) antibiotics, dicloxacillin and diclofenac, indamycin and ceftriaxone and rifampin, isoniazid, ethambutol, and pyrazinamide for 2 months and then treatment with rifampin and isoniazid for 4 months. The outcome of the events was not reported. On an unspecified date, the patient was discharged from the hospital. List of documents held by sender: none. Sender's Comments: This case refers to a 16 month old child who experienced Osteomyelitis after receiving DIPHTHERIA/TETANUS/5 HYBRID AC PERTUSSIS/IPV (MRC5)/HIB (PRP/T) VACCINE at the age of 2 months, 4 months and 6 months, simultaneously with hepatitis B vaccine, PNEUMOCOCCAL VACCINE, ROTAVIRUS VACCINE (other manufacturer). At the age of 6 months patient received BCG vaccine and at the age of 12 months MEASLES-MUMPS-RUBELLA, HEPATITIS A VACCINE and VARICELLA VACCINE (LIVE) (other manufacturer). At the age of 16 months, patient presented with ankle abscess and the acid fast bacillus culture of the wound discharge yielded a positive result for Mycobacterium Bovis, Bacillus Calmette Guerin (BCG). Based upon the available information, the reported event of Osteomyelitis resulted from BCG vaccine and the causality with other suspect vaccines can be excluded.