High Prevalence of Hepatitis Delta Virus among Persons Who Inject Drugs, Vietnam

Pathologic diagnosis of Mycobacterium infection from bony specimens was recorded for 35 (92%) patients. For 29 (76%), diagnosis was conducted by molecular study, including 25 (66%) by the national reference mycobacterial laboratory. For 4 patients, diagnosis was confirmed by culture of M. bovis. Osteomyelitis/osteitis for 5 patients was considered BCG related according to pathologic diagnosis of Mycobacterium infection, BCG vaccination history, and lack of a history of contact with a person with tuberculosis. Thirty-two (84%) children underwent surgery (exci-sion, debridement, open biopsy), 4 children received ar-throtomy (3 ankle and knee joint), and 2 children underwent only aspiration biopsy. All patients received isoniazid and rifampin therapy; 33 patients also received pyrazinamide, and 6 received additional ethambutol therapy. Medications were adjusted after diagnoses changed from tuberculosis to BCG infection. Two patients had major sequelae, both involving the thoracic spine and causing severe kyphosis. Adverse reactions after BCG vaccination depend on the BCG dose, vaccine strain, vaccine administration method, injection technique, and recipient's underlying immune status (5). The vaccine strain and manufacturing process in Taiwan did not change during the study period. Findings were not associated with a specific batch of vaccine , inoculation age, underlying disease, or Salmonella spp. infection. Patients had no common birth place, hospital , or area of residence. We believe the increased number of cases resulted mainly from policy changes and laboratory facility improvements. A surgical approach to obtain a specimen is indicated. However, because medical treatment usually yields a good outcome (6), extensive debridement should be avoided. Although some patients with lower extremity involvement initially limped, most were able to walk well later. Vertebral involvement is rare. Unlike previously reported cases (7,8), both patients reported here who had vertebral involvement had sequelae. For young children with suspected vertebral tuberculosis but no tuberculosis contact history, a biopsy specimen for BCG studies is preferable to spondylectomy. Although no definite immunologic deficit was found in these BCG osteomyelitis/osteitis patients, 2 other compensated infants with disseminated BCG during the same period in Taiwan had identified immunodeficiency (9). Studies are ongoing by the Taiwan Centers for Disease Control to evaluate medical treatment duration, long-term outcomes, and more detailed immune genetic tests. Acknowledgments We thank the members of the Taiwan Vaccine Injury Compensation Program committee for their evaluation of the relation between BCG and possible adverse reactions in the patients of this study. Couvet E. A bibliography of the complications of BCG vaccination. …