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Bacille Calmette -Guerin Vaccine-Induced Disease in Children with HIV/AIDS

Bacille Calmette -Guerin Vaccine-Induced Disease in Children with HIV/AIDS. HAIVN Harvard Medical School AIDS Initiatives in Vietnam. Learning Objectives. By the end of this session, participants should be able to:

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Bacille Calmette -Guerin Vaccine-Induced Disease in Children with HIV/AIDS

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  1. BacilleCalmette-Guerin Vaccine-Induced Disease in Children with HIV/AIDS HAIVN Harvard Medical School AIDS Initiatives in Vietnam

  2. Learning Objectives By the end of this session, participants should be able to: • Recognize clinical signs/symptoms suspicious for BCG disease in HIV-infected children • Identify different forms of BCG-related complications in HIV-infected children • Propose the appropriate work-ups and treatment for BCG

  3. BCG Vaccine: Overview (1) • M. bovis is part of the Mycobacterium tuberculosis complex • BCG (bacilleCalmette-Guérin) is: • a live attenuated strain of M. bovis, developed as a vaccine against TB disease • inherently resistant to PZA and may be resistant to INH • In TB-endemic countries including Vietnam, BCG is given at birth or shortly thereafter: • Although BCG does not provide 100% protection against TB, it does reduce the risk of severe disease, namely meningeal and miliary TB, in children • The rate of adverse effects due to the vaccine: • Before HIV: 0.19-2 cases/million vaccinated infants

  4. BCG Vaccine: Overview (2) • Healthy infants and children usually only develop: • injection site ulceration • or lymphadenitis • Because BCG is a live attenuated vaccine, it can cause disease in susceptible individuals: • HIV infected infants are at a much greater risk of BCG related complications • Disseminated disease: • only occurs in severely immunocompromised individuals, and • carries an extremely high mortality rate above 80% Prompt treatment with both anti-mycobacterial and ARV therapies increases chance of survival

  5. BCG Vaccine Recommendation • Give BCG vaccine to all HIV-exposed children • Postpone vaccination until HIV infection is excluded in the following situations: • High risk of HIV infection: mother and infant did not receive PMTCT, or • The infant presents with signs or symptoms suggestive of HIV infection, or • Low birth weight (under 2500 g) and pre-termed infants

  6. BCG-related Complications

  7. Suppurative Axillary Lymphadenitis (Regional Disease) • Ipsilateral to vaccine injection site • Can become extremely inflamed and painful • Take several months to subside • Needle drainage or lymph node excision may be necessary • If there are signs of dissemination, anti-TB treatment recommended

  8. Left Axillary Lymphadenitis

  9. Disseminated BCG Disease • Usually in young children with advanced HIV • Median age at onset is 8 months • Most common signs/symptoms: • Wasting, failure to thrive • Anemia, usually severe • Hepatosplenomegaly • Axillary, cervical adenitis • Osteomyelitis • Infiltrates on CXR

  10. Extensive bilateral infiltrates in a patient with disseminated BCG

  11. Work-up • Any child with left axillary lymph node adenitis: • CBC, AST/ALT, CD4 • CXR • Gastric aspirate, needle aspiration of lymph node: • send for AFB stain and culture with strain identification, drug susceptibility

  12. Treatment (1) • Local or regional disease: • RHE • PZA for 2 months or until TB excluded • Needle aspiration or FNA if node fluctuant • Consider LN excision • Start ART

  13. Treatment (2)

  14. Case Study

  15. Case Study (1) • 3 year-old boy, HIV+, presented with: • A left axillary lymph node and a left cervical LN • Also hepatosplenomegaly • What do you want to do about the lymph nodes?

  16. Case Study (2) • Aspiration of lymph node was positive for AFB • Do you want to do anything further with the aspirates?

  17. Case Study (3) • Patient was placed on TB therapy with 2RHZ/4RH • CD4 3 cells/mm3 • Started on AZT/3TC/EFV • Over the next 3 months, a lymph node drained and healed, and some other lymph nodes came up in the axilla. New lymph nodes appeared in cervical and supraclavicular areas • What do you think is going on?

  18. Case Study (4)

  19. Case Study (5) • After 3 months of ART, CD4 increased from 3 to 8 cells/mm3, no weight gain • What do you want to do? • Given poor clinical progression, he was switched to second line with LPV/r + 3TC + TDF • 6 months after, all LN resolved.

  20. Case Study (6) After 3 months on TB therapy and ARV

  21. Key Points • BCG can cause severe complications in HIV-infected children • BCG vaccine should not be given to infants at high risk of HIV infection or symptomatic infants • Anti-TB treatment and ARV should be started promptly for disseminated disease to improve chance of survival

  22. Thank you! Questions?

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