Age: 0.6
Sex: M
Vaccine: BCG, OPV
Symptoms: CSF protein normal, CSF white blood cell count increased, Chest X-ray normal, Computerised tomogram abnormal, Cytomegalovirus test negative
Clinical narrative: Initial literature report received on 11 October 2014. A 7-month-old male patient, whose concomitant medications were not reported, had received a dose of BCG (in left deltoid, batch number and route of administration were not reported) and a dose of OPV (batch number, route and anatomical site of administration were not reported) of unknown manufacturer on an unspecified date. The patient has a medical history of SCIDS (severe combined immunodeficiency). It was reported that, after vaccination, the patient was brought to hospital emergency department in July 2013; he had a 6-week history of intermittent fever associated with draining skin lesion over the left deltoid at the site of BCG vaccination. The patient was diagnosed with acute lymphadenitis and prescribed trimethoprim and sulfamethoxazole and sent home. The patient was again brought to the emergency department with increased irritability and decreased movement of the left leg and was admitted to the hospital for the further evaluation. The patient appeared tired and anxious but was responsive to touch. The physical examination was negative for meningococcal signs, no evidence of respiratory distress was found. A firm, mobile, tender, 2x2 cm mass was palpated under the left axilla. The patient did not move his left leg spontaneously or in response to pain. Deep tendon reflexes were absent in the left leg and diminished in the right. Decreased anal sphincter tone was noted. The rest of the physical examination was found to be normal. The patient was diagnosed with VAPP (vaccine-associated paralytic poliomyelitis) after laboratory investigations. Laboratory investigations: Complete blood count- ALC-216 cells/mm3, lymphocytes subsets- CD3 6 cells/mm3, CD4 2, CD8 0, CD 19 1, CD16/56 189, HIV 1/2 was negative, Immunoglobulins- IgA and IgM undetectable, IgG 140 mg/dl. Cerebrospinal fluid test: White blood cell 83 cell/mm3, Polymorph nuclear neutrophils 50%, mononuclear cells 2%, protein 48 mg/dl, glucose 49 mg/dl. Imaging: Chest radiograph was normal, Brain and Spine MRI showed 8 mm lesion in right cerebral peduncle, prominent abnormal T2 weighted signal at cord T11 level on the left: additional abnormal signal and contrast enhancement of several nerve roots. Chest, abdomen and pelvis CT scan showed enlarged lymph nodes, left supraclavicular, and left axilla, retroperitoneal. Microbiology: Blood test showed no bacterial growth at 48 hours, later positive for AFB identified as mycobacterium bovis/BCG. Cerebrospinal fluid showed negative bacterial meningitis screen and gram stain, negative fungal smear and culture, negative PCR for HSV-1, HSV-2 and CMV. Stool analysis- enterovirus isolated, identified as immunodeficiency associated vaccine derived poliovirus type, Lymph node fine needle aspiration showed AFB stain positive. On an unspecified date, the child progressed to respiratory distress during further observation. It was reported that after consultation with multiple specialist physicians and with ethics committee review, the family chose to withdraw support and the child died shortly thereafter. Documents held by sender: None.