Research Paper
Medical Science
E-ISSN No : 2454-9916 | Volume : 6 | Issue : 6 | June 2020
REACTIVATION OF THE BACILLUS CALMETTE GUERIN (BCG) SCAR COMMON WITH KAWASAKI DISEASE (KD) RARE WITH MEASLES: A CASE REPORT Dr. Subir Pal MBBS.DCH.MD.MIAP, Consultant Child Specialist, IRIS Hospital, Kolkata, India. Visiting Consultant AMRI, Mukundapur, India. ABSTRACT Erythema, induration at a previous BCG inoculation site highly specific feature of Kawasaki disease. It can also occur with measles though very rare (1). We find BCG reactivation in an 8 months old girl (Fig-1). Infants are protected from measles by the transplacentally acquired immunity from mother till the age of 4 to 6 months and these antibodies are undetectable by the age of 9 months(2). It means 8 months age is critical for development of measles in unvaccinated infant. KEY WORDS: Measles, Kawasaki Disease, BCG, Scar, Reactivation.
CASE PRESENTATION: A eight month old girl baby was presented initially with fever ,cough and coryza followed by erythematous skin rash and 2 cm area of induration of BCG scar site(Fig-2). On that time no other clinical features of KD were present. To the best of our knowledge the case report to describe BCG reactivation in child with measles is there[1].Laboratory confirmation by virus isolation from throat swab and also detection of measles specific antibodies [IGM] is not easily available and not done in this case. In 2017, 11000 people died from measles and increase to 140000 last year according to data compiled by the WHO [3].Considering age, clinical features vitamin A was given without any improvement. On day 5 baby was developed fissuring of lip, strawberry tongue and the hand, feet became swollen. Blood investigation revealed as follows, Hb-6.8 gm/dl.WBC-13700/Cmm, Platelet count-6lakh/Cmm,CRP- 143mg/L ,Echocardiography-Structurally normal heart with normal ventricular function. Dilated left main coronary artery.
changes(72%)(10).The significant risk factor for the development of coronary artery disease is delayed diagnosis of KD leading to the delayed administration of therapy(11).IKD(Incomplete Kawasaki Disease) cases are increasing with an incidence of 10 to 45% and early diagnosis is important to prevent the development of coronary artery disease in 15 to 25% of untreated patients (12). Treatment with IVIG 2gm/kg within first 10 days reduces the sequel of the vasculitis to 2-4%(13).Specific early sign of the KD as reactivation of BCG scar was first highlighted in the Japanese literature (14).
Fig. 2: Erythematous skin rash involving whole body of the same baby In conclusion, in this case we highlights BCG scar reactivation is an early sign of atypical KD, especially in countries like India where BCG vaccine is a part of National programme of immunization. The incidence of Kawasaki disease become higher during COVID-19 Pandemic. Fig. 1: Induration of BCG scar in a eight month old girl
REFERENCES: 1.
DISCUSSION: BCG scar reactivation can occur in KD and rarely with measles. This clinical manifestation can be a useful sign in making a diagnosis especially in the atypical KD(4).BCG is one of the most widely used vaccine globally for prevention of miliary tuberculosis, tubercular meningitis. It is administered in left upper arm intradermally following which a scar develops after few months (5).The usual phenomenon following intradermal inoculation of BCG vaccine are as follows ,a small papule appears around 2 months, gradually enlarges and ulcerate within 2 to 4 months and heals over the next few months (6).The possible mechanism of erythema and crusting of BCG with measles is the reactivation and multiplication of live but dormant mycobacterium bovis that may have been present at BCG vaccination site facilated by immune suppression with measle infection. Other possible mechanism of BCG reactivation is an immune mediated reaction. This reaction of BCG scar in Kawasiki disease may be due to cross reactivity between mycobacterial and human Heat Shock Protein (HSP),in particular mycobacterium HSP65 and human homologus HSP63(7,8).KD affect the children under the age of 4 years and with the peak incidence at 9 to 11 months of age(9).In infant the most common finding are fever (100%) and oral mucosal
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