Guttate psoriasis-like lesions following BCG vaccination

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Introduction

BCG vaccine is a live attenuated strain of

Mycobac-terium bovis.1This vaccine is used in Turkey on a national scale. It is accepted that vaccination with BCG provides protection against tuberculosis. The vaccination site normally heals in 3–6 months to a small white atrophic scar. The regional lymph nodes may enlarge but usually heal without breaking down. Tuberculin sensitivity appears 5–6 weeks after vacci-nation.2We report a case with guttate psoriasis-like lesions following BCG vaccination.

Case Report

A 7-year-old schoolboy was admitted to our clinic with erythematous, scaling multiple lesions that developed 1 week after the BCG vaccination. The first lesion developed on the left shoulder at the site of vaccination and spread to other sides of the body within a few days. The patient was otherwise healthy and had revealed no other disease within the preced-ing month. He only mentioned that he had received a BCG vaccination on the left deltoid area 1 week prior to the initiation of his present complaint. He had no history of psoriasis or known allergies, but his father and uncle had a history of psoriasis vulgaris.

Physical examination showed discrete, erythema-tous, scaling multiple lesions, which were 0.5–1 cm in diameter localized on the extremities and whole body (Fig. 1). A similar lesion was observed on the left shoulder at the site of vaccination (Fig. 2). Scalp, face, and palmo-plantar regions were not affected.

Brief Reports

Guttate Psoriasis-like Lesions following BCG Vaccination

by Rafet Koca, H. Cevdet Altinyazar, Gamze Numanog˘lu, and Murat Ünalacak

University, Faculty of Medicine, Department of Dermatology, Zonguldak, Turkey

Summary

A 7-year-old boy presented to our clinic with a 1-week history of guttate psoriasis-like lesions after BCG vaccination. Although the patient did not have any history of psoriasis, his father and uncle had a history of psoriasis vulgaris. He was treated successfully with topical corticosteroid. Complete healing was seen after 3 weeks and the patient was still in remission 4 months after the cessation of the therapy. We proposed that patients who have psoriasis or predisposition to psoriasis must be carefully followed after BCG vaccination.

Correspondence: Dr Rafet Koca, Zonguldak Karaelmas Üniversitesi, Uygulama ve Araștırma Hastanesi, Dermatoloji Anabilim Dalı, 67600 Kozlu, Zonguldak, Turkey. E-mail <rafkoca@yahoo.com>.

FIG. 1. Erythematous, scaling multiple lesions localized on the upper extremities and body. 11 fmh011 (to/d) 27/4/04 8:54 am Page 178

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Nails were normal. Routine laboratory investi-gations including antistreptolysin-O and pharyngeal culture were within normal limits.

Histological examination of the biopsy specimen taken from the lesion on the left shoulder revealed minimal hyperkeratosis, focal epidermal hyper-plasia, slightly elongated rete ridges, and an infiltrate composed of mononuclear cells in the upper dermis (Fig. 3).

The patient was successfully treated with topical corticosteroid within 3 weeks and we have not observed any relapse for 4 months.

Discussion

Complications that are seen after BCG vaccination are divided into two groups, specific and non-specific. Specific complications are directly related to

M. bovis, which is present live attenuated in the

vaccine. The specific complications that can be faced are lupus vulgaris, Koch phenomenon-like reaction, severe regional adenitis, local subcutaneous abscess, BCG osteitis, distant tissue tuberculosis, and generalized adenitis. Non-specific complications are keloid formation, epithelial cyst, eczematous changes, generalized hemorrhagic rashes, granulo-mas, and erythema nodosum.3

Guttate psoriasis is a distinctive form of psoriasis that typically affects children, adolescents, and young adults. The lesions are 0.5–1.5 cm in diameter located on the upper trunk and proximal extremities. Streptococcal throat infection frequently precedes the onset or flare of guttate psoriasis. Guttate psori-asis may also occur as an acute exacerbation of pre-existing plaque psoriasis.4

Querio, et al. described a male with psoriatic arthropathy after BCG immunotherapy for bladder carcinoma.5Bogdaszewska, et al. reported a case of

psoriasis after BCG vaccination.6Although measles and staphylococcal vaccines have been used previ-ously in the treatment of psoriasis,7,8we suggest that the vaccination may be a triggering factor of guttate psoriasis by stimulating the immune system with an unexplained mechanism.

Unfortunately, in developing countries like Turkey, tuberculosis is an important and growing problem. For this reason, BCG mass vaccination is necessary for our country. The aim of this report is to be a reminder that lesions can be flared or triggered after BCG vaccination in patients who have psoriasis or who have a predisposition to psoriasis.

References

1. Tappeiner G, Wolff K. Tuberculosis and other mycobacterial infections. In: Freedberg IM, Eisen A, Wolff K, et al. (eds), Fitz-patrick’s Dermatology in General Medicine, 5th edn. McGraw-Hill, New York, 1999; Vol. 2: 2274–92.

2. Verbow J. Local skin complications of BCG vaccination. A case report. Practitioner 1984; 228: 1069–71.

3. Sasmaz R, Altinyazar HC, Talican S, et al. Recurrent lupus vulgaris following repeated BCG (Bacillus Calmette Gueriné) vaccination. J Dermatol 2001; 28: 762–64.

4. Christophers E, Mrowietz U. Psoriasis. In: Freedberg IM, Eisen A, Wolff K, et al. (eds), Fitzpatrick’s Dermatology in General Medicine, 5th edn. McGraw-Hill, New York, 1999; Vol. 1: 495–521.

5. Queiro R, Ballina J, Weruaga A, et al. Psoriatic arthropathy after BCG immunotherapy for bladder carcinoma. Br J Rheumatol 1995; 34: 1097.

6. Bogdaszewska C, Brzewski M. Psoriasis vaccinalis (post-BCG).

Przegl Dermatol 1973; 60: 497–99.

7. Viktorinova M, Cerna I, Jorda V, Marsalek E. Staphylococcal vaccine in the treatment of psoriasis. Cesk Dermatol 1982; 57: 10–5.

8. Novotny F. Relation between psoriasis and measles. Z Hautkr 1982; 57: 439–40

BRIEF REPORTS

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FIG. 3. Histopathological findings from the lesion of the left shoulder (H&E, 10 40).

FIG. 2. The lesion on the left shoulder at the site of vaccination.

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