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Epidemiologic Notes and Reports Disseminated Mycobacterium bovis Infection from BCG Vaccination of a Patient with Acquired Immunodeficiency Syndrome

In December 1982, Kaposi's sarcoma and acquired immunodeficiency syndrome (AIDS) were diagnosed in a 29-year-old white homosexual man. A trial of vinblastine sulfate failed to decrease the progression of his skin lesions. In February 1984, when seen in a clinic in Tijuana, Mexico, he was given a BCG vaccination. The expected local lesion from the BCG vaccination healed normally within the next few weeks. In June, he developed chills and fever to 39.4 C (103 F), weakness, fatigue, anorexia, and a mild headache. In July, the site of BCG vaccination on his left arm ulcerated, draining a small amount of pus and blood. A previously enlarged lymph node in the left axilla increased substantially in size and became very tender. Because of the possibility of disseminated BCG infection, treatment was begun with INH 300 mg/day, ethambutol 25 mg/kg/day, and pyridoxine. He rapidly became afebrile and regained his feeling of well-being. The ulcer healed slowly, and the enlarged lymph node decreased in size and tenderness. Two blood cultures taken June 28 and a culture of the ulcerating lesion taken July 16 grew Mycobacterium bovis, BCG strain. A blood culture taken July 23, just before therapy, grew M. fortuitum. Reported by RE Winters, MD, School of Medicine, University of California, Los Angeles, LQ Hanh, MD, Tuberculosis Control Unit, Los Angeles County Dept of Health Svcs, J Chin, MD, State Epidemiologist, California State Dept of Health Svcs; Div of Tuberculosis Control, Center for Prevention Svcs, AIDS Br, Div of Viral Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: BCG vaccine contains live mycobacteria derived from a strain of M. bovis attenuated through years of serial passage in culture by Calmette and Guerin at the Pasteur Institute, Lille, France. Although BCG has been widely used throughout the world, its use in the United States is limited to those uncommon situations in which uninfected persons are repeatedly exposed to infectious tuberculosis, and other means of preventing infection cannot be applied (1). BCG has also been used to stimulate the immune system of patients with various cancers, especially malignant melanoma, with the objective of causing regression of the tumors (2). As with any vaccine containing live organisms, however, it is contraindicated in persons with severely impaired immune responses, including those with AIDS, because disseminated infection with the organism contained in the vaccine may result.

M. bovis and M. tuberculosis (the M. tuberculosis complex) are pathogenic for man and are distinct from the "atypical" mycobacteria that tend to be opportunistic. Infection with M. bovis or M. tuberculosis, even if disseminated, is generally not considered opportunistic and is, therefore, not used as a marker for AIDS in CDC's surveillance definition of AIDS (3). The BCG strain of M. bovis, however, being attenuated and not usually a cause of disease, may be considered an opportunist.

Of the 9,760 AIDS patients in the United States reported to CDC as of April 24, 1985, 2.7% were reported to have tuberculosis. Disseminated atypical mycobacterial infection, used as a marker for AIDS, was reported in 3.7%. Another 0.9% were reported to have disseminated infection with an undetermined species of mycobacteria. The true cumulative incidence of mycobacterial infections in AIDS patients is undoubtedly higher. The opportunistic infections reported to CDC's AIDS surveillance program are largely limited to those present at the time AIDS is diagnosed. Disseminated mycobacterial infections are not common among the initial opportunistic infections in AIDS patients, but in one series of 71 AIDS patients, 24 (34%) reportedly developed infection with M. avium complex organisms at some time during their illness (4). The great majority (94%) of the atypical mycobacterial infections reported to the AIDS surveillance program have been due to M. avium complex; 4% were due to M. kansasii; and 2%, to other species. Besides the patient reported here, only one other AIDS patient had disseminated M. fortuitum reported; the M. fortuitum cannot be explained by the BCG vaccine and may represent a contaminated culture rather than a true infection.

References

  1. ACIP. BCG vaccines. MMWR 1979;28:241-4.

  2. Lymoureux G, Turcotte R, Portelance V, eds. BCG in cancer immunotherapy. New York: Grune and Stratton, 1976.

  3. Selik RM, Haverkos HW, Curran JW. Acquired immune deficiency syndrome (AIDS) trends in the United States, 1978-1982. Am J Med 1984;76:493-500.

  4. Agins B, Spicehandler D, Della-Latta P, El-Sadr W, Simberkoff MS, Rahal JJ. M. avium-intracellulare infection in AIDS. Washington, D.C.: Interscience Conference on Antimicrobial Agents and Chemotherapy, 1984:229 (abstract #798).

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