BCG Infection Following Therapy of Infant Acute Lymphoblastic Leukemia

The Bacillus Calmette-Guérin (BCG) vaccine is widely administered in tuberculosis-endemic regions. BCG infection (BCGitis) is a rare vaccine adverse event seen in immunocompromised patients. While BCGitis is well documented in patients with inborn errors of immunity and acquired immunodeficiency, data on BCGitis in infants with hematological malignancies are scarce.

We retrospectively analyzed five cases of BCGitis in infants with acute lymphoblastic leukemia (ALL) and treated at a single tertiary pediatric oncology center. Clinical characteristics, timing of BCGitis in relation to anticancer therapy, immune parameters, management, and outcomes were reviewed.

The median age at ALL diagnosis was 1.5 months (range, 0.5-5.3); four patients had KMT2A rearrangements. All received BCG vaccination with the Russian BCG strain vaccine at birth. BCGitis developed during chemotherapy (n = 2), blinatumomab immunotherapy (n = 1), or post-hematopoietic stem cell transplantation (HSCT; n = 2). One patient with BCGitis during chemotherapy had a reactivation of BCGitis after HSCT. All cases presented as localized infection; one had regional lymphadenitis. BCGitis onset correlated with either T-cell reconstitution or therapy-induced cytopenia. Antimycobacterial therapy (levofloxacin, amikacin, isoniazid, and ethambutol) led to resolution in all cases.

BCGitis in infants with acute leukemia is a rare complication that is likely associated with chemotherapy-induced immunodeficiency or immune reconstitution following chemotherapy, immunotherapy, or HSCT. While manifestations are typically localized, careful management is required to prevent further complications. This is particularly crucial for patients undergoing HSCT, where prophylactic antimycobacterial therapy may be considered in selected high-risk settings.