면역기능이 정상인 영아에서 동경주 BCG 백신 접종 후 발생한 파종성 Mycobacterium bovis 감염 1예

A Case of Disseminated Mycobacterium bovis Infection after BCG Vaccination (Tokyo strain) in an Apparently Immunocompetent Infant

  • 백지연 (서울대학교 의과대학 소아과학교실) ;
  • 최재홍 (서울대학교 의과대학 소아과학교실) ;
  • 김민경 (서울대학교 의과대학 소아과학교실) ;
  • 최은화 (서울대학교 의과대학 소아과학교실) ;
  • 이환종 (서울대학교 의과대학 소아과학교실) ;
  • 박경운 (서울대학교 의과대학 진단검사의학과교실)
  • Paik, Ji Yeun (Department of Pediatrics, Seoul National University College of Medicine) ;
  • Choi, Jae Hong (Department of Pediatrics, Seoul National University College of Medicine) ;
  • Kim, Min Kyung (Department of Pediatrics, Seoul National University College of Medicine) ;
  • Choi, Eun Hwa (Department of Pediatrics, Seoul National University College of Medicine) ;
  • Lee, Hoan Jong (Department of Pediatrics, Seoul National University College of Medicine) ;
  • Park, Kyoung Un (Department of Laboratory Medicine, Seoul National University College of Medicine)
  • 투고 : 2011.03.08
  • 심사 : 2011.05.06
  • 발행 : 2011.06.25

초록

BCG는 M. bovis로부터 유래된 생백신으로 5-6세 미만의 소아 결핵 특히 결핵성 수막염이나 속립성 결핵과 같은 중증 결핵의 예방 효과가 인정되고 있다. BCG 접종 후 이상반응은 국소 궤양 형성, 국소 림프절염이 가장 흔하며, 드물지만 골수염, 파종성 감염과 같은 치명적인 합병증도 있다. 파종성 BCG 감염은 주로 면역저하 환자에게서 흔하게 관찰되며 면역 저하가 없는 소아에게서 발생한 파종성 BCG 감염은 국내 문헌상 보고가 없었다. 저자들은 13개월 여환이 BCG 접종 5개월 뒤 발생한 발열, 피부 결절 및 다발성 림프절 종대를 주소로 내원하여, 백 신 접종 부위 외에 2군데에서 M. bovis BCG를 확인한 후 파종성 BCG 감염으로 진단된 1례를 경험하였다. 환아는 isoniazid와 rifampin으로 치료받았으며 약 2주 간의 입원 치료 후 임상 증상이 호전되어 퇴원하였다. 3주뒤 외래 추적 관찰에서 역설적 반응으로 생각되는 림프 절 종대와 피부 결절이 진행하였으나 동일 약제를 유지하면서도 다시 임상 증상이 호전되었고 환아의 면역학적 검사상 이상 소견이 관찰되지 않았기에 이를 보고하는 바이다.

Bacille Calmette-Gu$\acute{e}$rin (BCG) vaccine is a live attenuated vaccine derived from Mycobacterium bovis. Frequent complications after BCG vaccination are localized ulcer formation and regional lymphadenitis, but there could be rarely severe systemic reactions to BCG vaccine such as osteomyelitis and disseminated BCG infection. Although disseminated BCG infection can be complicated in infants with underlying immunodeficiency after BCG vaccination, it is very unlikely to develop in immunocompetent infants or children. We report a 13-month-old infant who presented with fever, skin nodules, and multiple enlarged lymph nodes 5 months following BCG vaccination. She was diagnosed with disseminated BCG infection by PCRconfirmed M. bovis BCG infection at ${\geq}$2 anatomical sites beyond the region of vaccination. The patient showed no obvious evidence of immunodeficiency as judged on the basis of previous disease history, plasma immunoglobulin levels, B and T lymphocytes counts in peripheral blood, DHR (dihydrorhodamine 123 fluorescence) test and HIV test. She started antituberculous treatment with isoniazid and rifampin, and now, apparently her symptoms have been improved.

키워드

참고문헌

  1. Ministry of Health and Welfare, The Korean Insitute of Tuberculosis. The 7th national tuberculosis prevalence survey in 1995 in Korea 1995:8-12.
  2. The Korean Pediatric Society. [General recommendations on immunizations] In: Lee HJ, ed. Immunization guideline. 6th ed. Seoul: The Korean Pediatric Society, 2008;14-26.
  3. Trevenen CL, Pagtakhan RD. Disseminated tuberculoid lesions in infants following BCG vaccination. Can Med Assoc J 1982;127:502-4.
  4. World Health Organization. BCG Vaccine. WHO Position Paper. Weekly Epidemiological Rec 2004;79:27-38.
  5. Baek HS CJ, Moon SJ, Oh SH. Lymphadenitis following intradermal BCG vaccination. Korean J Pediatr 2006;49:46-50. https://doi.org/10.3345/kjp.2006.49.1.46
  6. Casanova JL, Blanche S, Emile JF, Jouanguy E, Lamhamedi S, Altare F, et al. Idiopathic disseminated bacillus Calmette-Guerin infection: a French national retrospective study. Pediatrics 1996;98:774-8.
  7. Levin M, Newport MJ, D'Souza S, Kalabalikis P, Brown IN, Lenicker HM, et al. Familial disseminated atypical mycobacterial infection in childhood: a human mycobacterial susceptibility gene? Lancet 1995;345:79-83. https://doi.org/10.1016/S0140-6736(95)90059-4
  8. Farhoudi A, Bazargan N, Arshi S, Pourpak Z. BCG dissemination in 40 patients and review of leukocyte mycobactericidal defect in one patient. Iran J Allergy Asthma Immunol 2000;1:63-7.
  9. Ferguson RG, Simes AB. BCG vaccination of Indian infants in Saskatchewan. Tubercle 1949;30:5-11. https://doi.org/10.1016/S0041-3879(49)80055-9
  10. Pedersen FK, Engbaek HC, Hertz H, Vergmann B. Fatal BCG infection in an immunocompetent girl. Acta Paediatr Scand 1978;67:519-23. https://doi.org/10.1111/j.1651-2227.1978.tb16363.x
  11. Kim SH, Kim SY, Eun BW, Yoo WJ, Park KU, Choi EH, et al. BCG osteomyelitis caused by the BCG Tokyo strain and confirmed by molecular method. Vaccine 2008;26:4379-81. https://doi.org/10.1016/j.vaccine.2008.06.004
  12. Fine PE. Variation in protection by BCG: implications of and for heterologous immunity. Lancet 1995;346:1339-45. https://doi.org/10.1016/S0140-6736(95)92348-9
  13. Kim KH, Lee SJ, Lee K. PPD conversion rate and complications according to the different time of BCG vaccination. J Korean Pediatr Soc 1987;30:487-90.
  14. Hesseling AC, Rabie H, Marais BJ, Manders M, Lips M, Schaaf HS, et al. Bacille Calmette-Guerin vaccineinduced disease in HIV-infected and HIV-uninfected children. Clin Infect Dis 2006;42:548-58. https://doi.org/10.1086/499953
  15. Deeks SL, Clark M, Scheifele DW, Law BJ, Dawar M, Ahmadipour N, et al. Serious adverse events associated with bacille Calmette-Guerin vaccine in Canada. Pediatr Infect Dis J 2005;24:538-41. https://doi.org/10.1097/01.inf.0000164769.22033.2c