Macías-Parra M, López-Corella E, Cardoso-Hernández G, Berrón-Pérez RD

Idioma: Español
Referencias bibliográficas: 41
Paginas: 145-150
Archivo PDF: 300.31 Kb.

RESUMEN

Los recién nacidos en México reciben sistemáticamente la vacuna BCG (Bacilo Calmette-Guérin, derivada de M. bovis) en los primeros días después del nacimiento; rara vez causan complicaciones serias. Sin embargo, puede ocurrir una infección diseminada en pacientes inmunodeficientes, en particular, en quienes tienen defectos de la inmunidad celular. En este informe, se describe uno de los dos únicos casos con autopsia, de enfermedad fatal diseminada por vacuna BCG estudiados en el Instituto Nacional de Pediatría (INP), Ciudad de México, entre diciembre de 1970 y diciembre del 2005. Se trató de un lactante de siete meses de edad que recibió la vacuna de BCG en el primer día de vida; dos meses después desarrolló linfadenitis regional y un absceso en el sitio de inyección, fiebre y crecimiento ganglionar en otros sitios. El niño tenía inmunodeficiencia combinada severa (IDCS). A los cinco meses de edad apareció tos; había detención de peso, talla. Una radiografía de tórax mostró que no había sombra tímica; infiltrado micronodular bilateral en la región parahiliar. Por esta razón se inició un tratamiento antituberculoso. El paciente empeoró gradualmente y falleció a los nueve meses de edad. En la autopsia se corroboró la ausencia del timo. Había hipoplasia severa del tejido linfoide; extensas zonas de un proceso granulomatoso con abundantes bacilos ácido-alcohol-resistentes intracelulares en bazo, hígado y ganglios linfáticos y neumocistosis en pulmón. En el INP la enfermedad diseminada por BCG ocurrió con una tasa de 1.5 casos por 10,000 egresos hospitalarios y dos casos/10,000 autopsias. La vacunación con BCG es un procedimiento generalmente seguro; sin embargo, en ocasiones puede tener complicaciones graves o incluso fatales sobretodo en pacientes con alteraciones en la respuesta inmune celular.

REFERENCIAS (EN ESTE ARTÍCULO)

1. Immunization policy. Global programme for vaccine and immunization. WHO/EPI/GEN/95.03 REV.1. World Health Organization. Expanded programme on Immunization. Childhood tuberculosis and BCG Vaccine. Genova. WHO. Update 1989; August.

2. World Health Organization, BCG vaccine: WHO position paper. Wkly Epidemiol Rep 2004;79:25-40.

3. Cobertura con esquema completo y con tipo de vacuna. Segundo censo nominal Diciembre 2002. Consejo Estatal de vacunación. PROVAC.2002 SSA. México.

4. Milstein JB, Gibson JJ. Quality control of BCG vaccine by WHO: a review of factors that may influence vaccine effectiveness and safety. Bull World Health Org 1990;68:93–108.

5. Bellet JS, Prose SS. Skin complications of Bacillus Calmette-Guérin immunization. Curr Op Infect Dis 2005;18:97-100.

6. Lugosi L. Theoretical and methodological aspects of BCG vaccine from the discovery of Calmette and Guerin to molecular biology. A review. Tuberc Lung Dis 1992;73:252-61.

7. Hengster P, Schnapka J, Fille M, Menardi G. Occurrence of suppurative lymphadenitis after a change of BCG vaccine. Arch Dis Child 1992;67:952-5.

8. CDC. ACIP: Use of BCG vaccines in the control of tuberculosis: A joint statement by the ACIP and the Advisory Committee for Elimination of Tuberculosis. MMWR 1988;37:663-4, 669-75.

9. Lotte A, Wasz-Höckert O, Poisson N, Dumitrescu N, Verron M, Couvet E. BCG complications. Estimates for the risk among vaccinated subjects and statistical analysis of their main characteristics. Adv Tuberc Res 1984;21:107-93.

10. Lotte A, Ten Dam HG, Henderson R. Second IUATLD study on complications induced by intradermal BCG vaccination. Bull Int Union Tuberc Lung Dis 1988;63:47-59.

11. Casanova JL, Jouanguy E, Lamhamedi S, Blanche S, Fisher A. Immunological conditions of children with BCG disseminated infection [letter]. Lancet 1995;26:346:581.

12. Fieschi C, Dupuis S, Catherinot E, Feinberg J, Bustamante J, Breiman A, et al. Low penetrance, broad resistance, and favorable outcome of interleukin 12 receptor beta1 deficiency: medical and immunological implications. J Exp Med 2003;197:527-35.

13. Jouanguy E, Altare F, Lamhamedi S, Revy P, Emile JF, Newport M, et al. Interferon-gamma receptor deficiency in an infant with fatal bacille Calmette-Guerin infection. N Engl J Med 1996 26;335:1956-61.

14. Pasic S, Lilic D, Pejnovic N, Vojvodic D, Simic R, Abinum M. Disseminated Bacillus Calmette-Guérin infection in a girl with hyperimmunoglobulin E syndrome. Acta Pediatr 1998;87:702-4.

15. Mackay A, Macleod T, Alcorn MJ, Laidlaw M, Macleod IM, Millar JS, et al. Fatal disseminated BCG infection in an 18-year-old boy. Lancet 1980;2:1332-4.

16. Pedersen FK, Engbaek HC, Hertz H, Vergmann B. Fatal BCG infection in an immunocompetent girl. Acta Paediatr Scand 1978;67:519-23.

17. González B, Moreno S, Burdach R, Valenzuela MT, Henríquez A, Ramos MI, et al. Clinical presentation of Bacillus Calmet-Guérin infections in patients with immunodeficiency syndromes. Pediatr Infect Dis J 1989;8:201-6.

18. Passwell J, Katz D, Frank Y, Spirer Z, Cohen BE, Ziprkowski M. Fatal disseminated BCG infection. An investigation of the immunodeficiency. Am J Dis Child 1976;130:433-6.

19. Esterly JR, Sturner WQ, Esterly NB, Windhorst DB. Disseminated BCG in twin boys with presumed chronic granulomatous disease of childhood. Pediatrics 1971;48:141-4.

20. Hikita H, Wakita S, Okuni M. A female case of chronic granulomatous disease. Clin Immunol (Jpn) 1973;5:653-9.

21. Bonnevier JO, Killander J, Olding L, Vahlquist B.Congenital agammaglobulinaemia in the brother of a boy who died of generalized BCG infection. Acta Paediatr 1964;53:55-64.

22. Bouton J, Mainwaring D, Smithells RW. BCG dissemination in congenital hypogammaglobulinaemia. Br Med J 1963;(8):1512-5.

23. Smith E, Thybo S, Bennedsen J. Infection with Mycobacterium bovis in a patient with AIDS: a late complication of BCG vaccination . Scand J Infect Dis 1992;24:109-10.

24. O’Brien KL, Ruff AJ, Louis MA, Desormeaux J, Joseph DJ, McBrien M, et al. Bacillus Calmette-Guerin complications in children born to HIV-1-infected women with a review of the literature. Pediatrics 1995;95:414-8.

25. Young LS. Mycobacterial diseases and the compromised host. Clin Infect Dis 1993;17(Suppl 2):S436-441.

26. Talbot E, Perkins M, Silva SFM, Frothiham R. Disseminated bacille Calmette-Guérin disease after vaccination: case report and review. Clin Infect Dis 1997;24:1139-46.

27. Cooper AM, Flynn JL. The protective immune response to Mycobacterium tuberculosis. Curr Opin Immunol 1995;7:512-16.

28. Stephan JL, Vlekova V, Le Deist F, Blanche S, Donadieu J, De Saint-Basile G, Durandy A, Griscelli C, Fischer A. Severe combined immunodeficiency: a retrospective single-center study of clinical presentation and outcome in 117 patients. J Pediatr 1993;123: 564-72.

29. Jouanguy E, Döffinger R, Dupuis S, Pallier A, Altare F, Casanova JL. IL-12 and IFN-g in host defense against mycobacteria and salmonella in mice and men. Curr Opin Immunol 1999;11:346-51.

30. Sallusto F, Lanzavecchia A, Mackay CR. Chemokines and chemokine receptors in T-cell priming and Th1/Th2-mediated responses. Immunol Today 1998;19:568-74.

31. Bancroft GJ, Schreiber RD, Bosna GC. A T cell independent mechanism of macrophage activation by interferon gamma. J Immunol 1987;139:1104.

32. Skinner R, Appleton AL, Sprott MS, Barer MR, Magee JG, Darbyshire PJ, et al. Disseminated BCG infection in severe combined immunodeficiency presenting with severe anaemia and associated with gross hypersplenism after bone marrow transplantation. Bone Marrow Transplant 1996;17:877-80.

33. Notarangelo LD, Giliani S, Mazza C, Mella P, Savoldi G, Rodriguez-Perez C, et al. Of genes and phenotypes: the immunological and molecular spectrum of combined immune deficiency. Defects of the gamma(c)-JAK3 signaling pathway as a model. Immunol Rev 2000;178:39-48.

34. Levy Y, Hershfield MS, Fernández-Mejia C, Polmar SH, Scudiery D, Berger M, et al. Adenosine deaminase deficiency with late onset of recurrent infections: response to treatment with polyethylene glycol-modified adenosine deaminase (PEGADA). J Pediatr 1988;113:312-7.

35. Villa A, Sobacchi C, Notarangelo LD, Bozzi F, Abinun M, Abrahamsen TG, et al. V(D)J recombination defects in lymphocytes due to RAG mutations: severe immunodeficiency with a spectrum of clinical presentations. Blood 2001;97:81-8.

36. Puel A, Leonard WJ. Mutations in the gene for the IL-7 receptor result in T–B+NK+ severe combined immunodeficiency disease. Curr Opin Immunol 2000;12:468-73.

37. Kung C, Pingel JT, Heikinheimo M, Klemola T, Varkila K, Yoo LI, et al. Mutations in the tyrosine phosphatase CD45 gene in a child with severe combined immunodeficiency disease Nature Med 2000;6:343–5.

38. Colditz CA, Berkey CS, Mosteller F, Brewer TF, Wilson ME, Burdick E, et al. The efficacy of Bacillus Calmette-Guérin vaccination of newborns and infants in the prevention of tuberculosis: Meta-analyses of the published literature. Pediatrics 1995;96:29-35.

39. Colditz CA, Brewer T, Berkey CS, Mosteller F, Wilson ME, Burdick E, et al. Efficacy of BCG in the prevention of tuberculosis: Meta-analyses of the published literature. JAMA l994;171:698-702.

40. Ponnighaus JM, Fine PE, Sterne JA, Wilson RJ, Msosa E, Gruer PJ, Jenkins PA, Lucas SB, Liomba NG, Bliss L. Efficacy of BCG vaccine against leprosy and tuberculosis in Northern Malawi. Lancet 1992;(14):339:636-9.

41. Karonga Prevention Trial Group. Randomised controlled trial of single BCG, repeated BCG, or combined BCG and killed Mycobacterium leprae vaccine for prevention of leprosy and tuberculosis in Malawi. Lancet 1996;348:17-24.