A Case Diagnosed with Chronic Granulomatous Disease After Disseminated Infection Following BCG Vaccination

BCG (Bacillus Calmette-Guérin) aşısı, çocukları miliyer tüberküloz (TB) ve TB menenjitinden korumak amacıyla Dünya Sağlık Örgütü'nün önerisiyle yaygın olarak kullanılan bir aşıdır. Aşıya bağlı ciddi yan etkiler, sıklıkla altta yatan immün yetmezlik varlığında görülür. Bu raporda, kronik granülomatöz hastalık (KGH) taşıyıcısı olduğu bilinmeden BCG aşısı uygulanan ve aşı sonrası disemine BCG enfeksiyonu gelişen bir bebek olgu sunulmuştur. Bilinen bir sağlık problemi olmayan 3 ay 28 günlük bir kız çocuğunda, BCG aşısı sonrası yüksek ateş, sol aksiller lenfadenopati ve hepatosplenomegali gelişmiştir. Olgunun aksiller lenf bezi eksizyon materyalinin Löwenstein-Jensen besiyerinde yapılan kültüründen aside dirençli basil (ARB) izole edilmiş ve Mycobacterium bovis olarak tanımlanmıştır. Lenf bezi dokusu örneğinden yapılan polimeraz zincir reaksiyonu testinde Mycobacterium tuberculosis kompleks DNA'sı pozitif bulunmuştur. Hastaya rifampisin 20 mg/kg + izoniyazid 10 mg/kg + etambutol 15 mg/kg + streptomisin 30 mg/kg dozunda antitüberküloz tedavi başlanmıştır. İmmün yetmezlik açısından değerlendirilmek üzere dihidroamin ve LAD (lenfosit adezyon defekti) testleri çalışılmış ve alınan sonuçlara göre hastaya otozomal resesif tipte KGH tanısı konulmuştur. Olgunun yenidoğan döneminde tespit edilen ya da ailesinde bilinen herhangi bir immün yetmezlik öyküsü olmadığı öğrenilmiştir. Hastaya, tüberküloz için endemik bölgelerde yaşayan KGH hastalarında kullanımı önerilen interferon-gama tedavisi uygulanmıştır. Antitüberküloz tedavinin 15. gününde olgunun ateşi düşmüş, 35. gün tedavisine evde devam etmek üzere taburcu edilmiştir. Poliklinikten takibine devam edilen hastanın ek bir şikayeti olmamış ve üçüncü ayda hepatosplenomegalisi tamamen düzelmiştir. Sonuç olarak, KGH taşıyıcılarında BCG aşısı kontrendike olduğundan, ailesinde KGH öyküsü olan yenidoğanlar immünolojik olarak tetkik edilmeli ve sonuçlar elde edilinceye kadar BCG aşısından kaçınılmalıdır. Aile öyküsü olmayan ve BCG aşısı sonrası mikobakteri enfeksiyonu tanısı konulan bebekler mutlaka immün yetmezlik açısından değerlendirilmelidirBCG (Bacillus Calmette-Guérin) vaccine is a widely used vaccine with the recommendation of World Health Organization to protect children against miliary tuberculosis (TB) and TB meningitis. Severe side effects related to this vaccine mostly manifest in the presence of underlying immunosuppressive disease. In this report, an infant case with unknown chronic granulomatous disease (CGD) who developed disseminated BCG infection after administration of BCG vaccine, was presented. High fever, left axillary lymphadenopathy and hepatosplenomegaly have developed in a 3-month 28-day female infant, without a known health problem, following BCG vaccination. The acid-fast bacilli (ARB) was isolated from the material of excised lymph node cultivated in Löwenstein-Jensen medium, and the isolate was identifi ed as Mycobacterium bovis. Mycobacterium tuberculosis complex DNA was detected in the axillary lymph node sample by polymerase chain reaction. Anti-tuberculous treatment included 20 mg/kg of rifampicin + 10 mg/kg of isoniazid + 15 mg/kg of ethambutol + 30 mg/kg of streptomycin was started. The patient was then further evaluated for immunodefi ciency and on the basis of the results of dihydroamine and LAD (lymphocyte adhesion defect) tests, diagnosed as autosomal recessive CGD. Based on the anamnesis, there was no known immunodefi ciency history both in the case during neonatal period and her family members. Interferon-gamma therapy, which is recommended for the patients with CGD living in endemic areas, was initiated. Our patient's fever dropped at the 15th day of anti-tuberculosis treatment, and she was discharged on the 35th day and continued to receive treatment at home. The patient was followed up at outpatient clinic and had no additional complaints; her hepatosplenomegaly was back to normal at the third month. As a result, since BCG vaccine is contraindicated in CGD carriers, newborns with a family history of CGD should be immunologically examined and BCG vaccine should be avoided until the results are obtained. In addition, newborns without a family history, diagnosed as disseminated mycobacterial infection following BCG vaccination, should be evaluated for an underlying immunodefi ciency conditio

Neurobrucellosis; Three Case Reports

Various systematic complications occur in up to 30% of patients with brucellosis however brucellosis may involve central nervous system in only 2-5% of patients. In this study, the clinical and laboratory characteristics and therapeutic approach of three cases of neurobrucellosis (in a case series of 86 brucellosis patients) followed in our clinic between 1990-2004 were evaluated retrospectively. Cranial nerve involvement was present in all of these cases. Diagnosis was made based on the clinical features and pathological cerebrospinal fluid (CSF) findings and presence of the specific brucellosis antibodies in CSF. Rose-Bengal tests and Wright agglutination tests were positive in all cases. Three cases of neurobrucellosis treated with a combination of rifampicin, doxycycline and trimetoprim-sulphametoxazole for a period of six months and they become disease free, completely. As a conclusion, neurobrucellosis should be considered especially in the differential diagnosis of meningitis of undetermined origin where brucellosis is endemic like Turkey and other Mediterranean basin countries

The Comparison of Anterior and Posterior Surfaces and Core of Tonsil Microflora in Recurrent Acute Tonsillitis

This study was performed to evaluate the anterior and posterior surfaces and deep tissue localized flora cultures of 76 tonsils recovered from 15 children and 27 adults. As 8 of the tonsil specimens were not appropriate, they were not included in the study. The detection of pathogens at the anterior sides, the cores, and the posterior sides were 29%, 21%, and 18% in all of the tonsils. No bacteria were isolated from the cores of four materials. The detection of pathogens at the anterior sides, the cores, and the posterior sides were 44%, 37%, and 37% in children and 20%, 12%, and 8% in adults respectively. The beta-lactamase activities of S. aureus, M. catarrhalis and H. influenzae strains were 28%, 59% and 32% at the anterior side, 23%, 50%, and 19% at the core, 34%, 47%, and 25% at the posterior side respectively. The results of our study indicated that S. pyogenes was seen at tonsil surface at higher rates than tonsil core and encountered in children’s tonsils more than adults tonsils

Advances in Health and Disease. Volume 40

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