The case is a female patient of 21 months old, who presented an increase in volume in the right pelvic limb. The patient has a complete vaccination for her age with application of BCG on April 30th, 2015. The mother reported a clinical picture of approximately 2 months of evolution, characterized by pain in the bone at the traction of pelvic limb with subsequent claudication to walk. She denies the presence of fever, weight loss, hyporexia or any other symptom.
The patient was then referred to the Oncology Service to begin a procedure of bone tumor management in the anterior tibia of the right leg after denial of the above symptoms, traumatic antecedent or recurrent infection of the airways. Paraclinical studies reported 11.3 g/dL of hemoglobin, 33.8% of hematocrit, 9.5 (103/mm3) of leucocytes, 1.3 (103/mm3) of neutrophils, 6.9 (103/mm3) lymphocytes, 1 (103/mm3) of monocyte, 319 (103/mm3) of platelets, 16 (mm/h) of globular sedimentation rate (GSR) and <0.316 (mg/dL) of C reactive protein (CRP). The X-ray of the right pelvic limb depicted a delimited metaphyseal lytic lesion of the proximal right tibia with periosteal reaction and geographical pattern, and increased volume of the soft tissues, as well as metastatic bone series without evidence of other lesions. In magnetic resonance imaging (MRI), compatible chronic granulomatous osteomyelitis lesion was detected, (Fig. 1). Based on these evidences, the patient was transferred to Infectious Disease Service to continue his management procedures. The patient was subjected to Purified Peptide Derivative (PPD) test and resulted to be negative with a value of 3x3 mm. Chest X-ray was performed and it ruled out lung compromise (Fig. 2). High resolution tomography of the lung carried out in search of mediastinal adenopathies suggestive of Tuberculosis was without apparent aggregated lesions. Curettage was done with subsequent application of cryotherapy and graft placement at the site of the lesion. Biopsy of the bone was performed obtaining a culture with histopathological characteristics suggestive of Mycobacterium tuberculosis (Fig. 3). In genotype analysis of the sample, Mycobacterium bovis (BCG) was identified as the causative agent; thus confirming the association of the lesion with the application of the vaccine in this patient. Sensitivity test performed confirmed the susceptibility of the agent to Isoniazid, Rifampicin, Ethambutol, and Streptomycin. In view of this, antimicrobial scheme based on Clarithromycin 80 mg/kg/day, Ethambutol 20 mg/kg/day, Rifampicin 10 mg/kg/day, and Isoniazid 10 mg/kg/day was started and then began to improve favorably.