Bacillus Calmette–Guérin Vaccine-associated Complications in Immunodeficient Patients Following Liver Transplantation

To the Editors: Bacillus Calmette–Guérin (BCG) is a live attenuated Mycobacterium bovis used as a vaccine against tuberculosis. In our country, it is typically administered during the 2nd month of childhood.1 It is recommended that the live vaccine not be administered within 4 weeks before transplantation, because the risk of BCG disease in these patients is unknown.2 An 11-month-old female patient diagnosed with biliary atresia who had undergone liver transplantation 4 months previously was admitted to our hospital with complaints of redness, swelling and purulent secretion in the area where the BCG vaccine was administered. The patient's purified-protein derivative test result was 0 mm, and the BCG vaccine was administered 1.5 months before liver transplantation. Redness and swelling started 2 months after the transplant, and purulent secretion started 1 week before admission to our hospital. The patient who received immunosuppressive therapy had no history of contact with a patient diagnosed with tuberculosis. On physical examination, a 1.5 cm diameter hyperemic, necrotic, yellow purulent secretion lesion was observed in the left shoulder region where the BCG vaccine was applied, and lymphadenomegaly (0.5 cm) was detected in the left axilla (Fig. 1). The patient was diagnosed with local BCGitis disease. The patient was treated with rifabutin instead of isoniazid or rifampicin due to concerns about drug interactions and toxicity. Complete resolution with a scar at the injection site was observed after treatment, and no palpable lymph nodes were observed.FIGURE 1.: 1.5 cm diameter hyperemic, necrotic, yellow purulent secretion lesion in the left shoulder.Adverse reactions after BCG infection range from 1% to 10%, mostly occurring within the first 6 months after vaccination.3 The frequency of adverse reactions is influenced by vaccine and host factors, including dosage, BCG strain, administration technique, age at vaccination and host immune status.4 It is recommended that the BCG vaccine not be administered within 4 weeks before transplantation because the risk of BCG disease in these patients is unknown. Kinoshita et al5 reported that they did not observe complications after BCG vaccination in their pediatric transplant series, although 2 patients were vaccinated after transplantation.5 Treating tuberculosis in solid organ transplantation patients can be a challenge because the interactions between rifampicin and the immunosuppressive drugs rifabutin offer a reliable alternative to rifampin when treating tuberculosis in solid organ transplantation recipients.6 In our patient, although there were 1.5 months between transplantation and vaccination, a reaction developed. The present case was reported to address this issue.