In December 1982, Kaposi's sarcoma and acquired
immunodeficiency
syndrome (AIDS) were diagnosed in a 29-year-old white homosexual
man.
A trial of vinblastine sulfate failed to decrease the progression
of
his skin lesions. In February 1984, when seen in a clinic in
Tijuana,
Mexico, he was given a BCG vaccination. The expected local lesion
from the BCG vaccination healed normally within the next few weeks.
In June, he developed chills and fever to 39.4 C (103 F), weakness,
fatigue, anorexia, and a mild headache. In July, the site of BCG
vaccination on his left arm ulcerated, draining a small amount of
pus
and blood. A previously enlarged lymph node in the left axilla
increased substantially in size and became very tender. Because of
the possibility of disseminated BCG infection, treatment was begun
with INH 300 mg/day, ethambutol 25 mg/kg/day, and pyridoxine. He
rapidly became afebrile and regained his feeling of well-being.
The
ulcer healed slowly, and the enlarged lymph node decreased in size
and
tenderness. Two blood cultures taken June 28 and a culture of the
ulcerating lesion taken July 16 grew Mycobacterium bovis, BCG
strain.
A blood culture taken July 23, just before therapy, grew M.
fortuitum.
Reported by RE Winters, MD, School of Medicine, University of
California, Los Angeles, LQ Hanh, MD, Tuberculosis Control Unit,
Los
Angeles County Dept of Health Svcs, J Chin, MD, State
Epidemiologist,
California State Dept of Health Svcs; Div of Tuberculosis Control,
Center for Prevention Svcs, AIDS Br, Div of Viral Diseases, Center
for
Infectious Diseases, CDC.
Editorial Note
Editorial Note: BCG vaccine contains live mycobacteria derived
from a
strain of M. bovis attenuated through years of serial passage in
culture by Calmette and Guerin at the Pasteur Institute, Lille,
France. Although BCG has been widely used throughout the world,
its
use in the United States is limited to those uncommon situations in
which uninfected persons are repeatedly exposed to infectious
tuberculosis, and other means of preventing infection cannot be
applied (1). BCG has also been used to stimulate the immune system
of
patients with various cancers, especially malignant melanoma, with
the
objective of causing regression of the tumors (2). As with any
vaccine containing live organisms, however, it is contraindicated
in
persons with severely impaired immune responses, including those
with
AIDS, because disseminated infection with the organism contained in
the vaccine may result.
M. bovis and M. tuberculosis (the M. tuberculosis complex) are
pathogenic for man and are distinct from the "atypical"
mycobacteria
that tend to be opportunistic. Infection with M. bovis or M.
tuberculosis, even if disseminated, is generally not considered
opportunistic and is, therefore, not used as a marker for AIDS in
CDC's surveillance definition of AIDS (3). The BCG strain of M.
bovis, however, being attenuated and not usually a cause of
disease,
may be considered an opportunist.
Of the 9,760 AIDS patients in the United States reported to CDC
as
of April 24, 1985, 2.7% were reported to have tuberculosis.
Disseminated atypical mycobacterial infection, used as a marker for
AIDS, was reported in 3.7%. Another 0.9% were reported to have
disseminated infection with an undetermined species of
mycobacteria.
The true cumulative incidence of mycobacterial infections in AIDS
patients is undoubtedly higher. The opportunistic infections
reported
to CDC's AIDS surveillance program are largely limited to those
present at the time AIDS is diagnosed. Disseminated mycobacterial
infections are not common among the initial opportunistic
infections
in AIDS patients, but in one series of 71 AIDS patients, 24 (34%)
reportedly developed infection with M. avium complex organisms at
some
time during their illness (4). The great majority (94%) of the
atypical mycobacterial infections reported to the AIDS surveillance
program have been due to M. avium complex; 4% were due to M.
kansasii;
and 2%, to other species. Besides the patient reported here, only
one
other AIDS patient had disseminated M. fortuitum reported; the M.
fortuitum cannot be explained by the BCG vaccine and may represent
a
contaminated culture rather than a true infection.
References
ACIP. BCG vaccines. MMWR 1979;28:241-4.
Lymoureux G, Turcotte R, Portelance V, eds. BCG in cancer
immunotherapy. New York: Grune and Stratton, 1976.
Selik RM, Haverkos HW, Curran JW. Acquired immune deficiency
syndrome (AIDS) trends in the United States, 1978-1982. Am J
Med
1984;76:493-500.
Agins B, Spicehandler D, Della-Latta P, El-Sadr W, Simberkoff
MS,
Rahal JJ. M. avium-intracellulare infection in AIDS.
Washington,
D.C.: Interscience Conference on Antimicrobial Agents and
Chemotherapy, 1984:229 (abstract #798).
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