Disseminated cutaneous tuberculosis from BCG vaccination site in an immunocompetent child

A healthy 4‐month‐old girl presented with widespread scaly papules and a nodule over the site of BCG immunization. A diagnosis of disseminated cutaneous tuberculosis in an immunocompetent child was confirmed with biopsy. The child was treated with antituberculosis therapy without recurrence.     

Lupus vulgaris at the site of BCG vaccination: report of three cases

Lupus vulgaris (LV) is a rare complication of the bacille Calmette–Guérin (BCG) vaccination, and about 65 cases of inoculation tuberculosis resembling LV have been reported in the literature. We report three cases of LV, developing many years later at the inoculation site of BCG vaccine. All three cases had a single BCG vaccination, with a LV lesion at or in the vicinity of the vaccination site, a strong positive Mantoux test, noncaseating granuloma histologically, and two of the patients had a positive PCR result for mycobacterial complex. One of the patients had an unusually delayed appearance of the LV lesion, after an interval of about 17 years, and another case was remarkable because of the large size of the lesion (210 × 110 mm).     

Recurrent lymphangitic cellulitis syndrome: A quintessential example of an immunocompromised district

Recurrent lymphangitic cellulitis syndrome (RLCS) occurs when a disordered lymphatic system renders a leg vulnerable to recurrent infection. The underlying immunologic defect is the result of accidental or iatrogenic penetrating wounds on the medial aspect of the thigh or lower limb overlying the greater saphenous vein, because the primary lymphatic drainage vessels are adjacent to this structure. Cracking/fissuring of the skin associated with chronic fungal infection of the feet (“athlete’s foot”), most commonly mixed bacterial/fungal interdigital involvement, provides a portal of entry for opportunistic organisms. Bacteria and their products are cleared more slowly in the lymphatic-disrupted and therefore immunologically impaired limb, producing broad areas of dermatitis and around the scars quite distinct from other forms of superficial infection. This rarely develop in otherwise normal limbs. The dermatitis of RLCS and its systemic effects clear with antibiotics but recur intermittently until the tinea pedis is eradicated. The contralateral limb with normal lymphatic structures never develops clinical evidence of infection even though bilateral tinea infection is almost always present. This confirms the central role of an anatomically induced immunocompromised district (ICD) in this syndrome.     

Nodular hidradenoma arising on the site of a BCG scar

Hidradenomas are tumours that arise from the adnexal structures, both eccrine and apocrine and are histologically benign. The tumours that arise from eccrine differentiation are known as poroid hidradenomas and when they arise from the apocrine glands they are called nodular hidradenomas. In our centre a 13‐year‐old boy presented with a slow‐growing, painless erythematous fungating nodule on the left upper arm over a period of 18 months at the site of the BCG vaccination. The nodule was surgically excised and sent for histopathological examination, leading to a diagnosis of nodular hidradenoma. This case is presented to highlight its rarity, together with its clinical features that were suggestive of malignancy but proved ultimately to be benign.     

The immunocompromised district: a unifying concept for lymphoedematous, herpes-infected and otherwise damaged sites

Systemic immunodeficiency is known to facilitate the onset of opportunistic infections, tumours and immune disorders in any district of the body. There are clinical events, such as chronic lymphoedema, herpetic infections, vaccinations and heterogeneous physical injuries which can selectively damage and immunologically mark the cutaneous district they act upon. After the causing event has disappeared, the affected district may appear clinically normal, but its immune behaviour is often compromised forever. An immunocompromised district becomes a site which is particularly susceptible to subsequent outbreaks of opportunistic infections, tumours and immune disorders confined to the district itself.
In this review, there is an ample case-report collection of opportunistic disorders (infectious, neoplastic, immune) which appeared in immunocompromised districts. The cases have been grouped according to the clinical settings responsible for the local immune imbalance: regional chronic lymphoedema; herpes-infected sites, which feature the well-known Wolf's isotopic response; and otherwise damaged areas, comprising sites of vaccination, ionizing or UV radiation, thermal burns and traumas.
Whatever the immunocompromising factor, a common denominator which facilitates the occurrence of tumours, infections and dysimmune reactions in an immunocompromised district may reside in locally hampered lymph drainage and/or locally altered neuromediator signalling. In fact, any obstacle to the normal trafficking of immunocompetent cells through lymphatic channels or any interference with the signals that the neuropeptides and neurotransmitters released by peripheral nerves send to cell membrane receptors of immunocompetent cells, can significantly alter the local immune response, thus paving the way for heterogeneous opportunistic disorders in the immunocompromised district.     

Radiation dermatitis,burns, and recall phenomena: Meaningful instances of immunocompromised district

Ionizing and ultraviolet radiations, as well as burns, can selectively damage and immunologically mark the cutaneous area they act on through direct and indirect mechanisms. After the causal event has disappeared, the affected skin district may appear clinically normal, but its immune behavior is often compromised forever. In fact, irradiated or burned skin areas undergo a destabilization of the immune control, which can lead to either a reduction of immunity (as suggested by the facilitated local occurrence of tumors and infections) or an excess of it (as suggested by the possible local onset of disorders with exaggerated immune response). In other words, these areas become typical immunocompromised districts (ICD). Also, in recall phenomena the damaged skin area usually behaves as an ICD with an exaggerated immune response toward a wide range of drugs (especially chemotherapeutic agents) that prove to be harmless on the undamaged skin surface.