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BCG scar changes in Kawasaki's disease

Three Part Question

In [children with suspected Kawasaki disease] [does the presence of skin changes at the BCG scar site] [aid in making a diagnosis]

Clinical Scenario

You are seeing a 3yr old girl in the ED. She has fever, red tongue and conjunctivitis. Her mother mentions her BCG scar looks more red than usual. You wonder if this is significant.

Search Strategy

Medline and Embase using NHS Evidence 195016th April 2012
(kawasaki.ti,ab OR exp Mucocutaneous Lymph Node Syndrome) AND (BCG.ti,ab; OR exp BCG Vaccine) Limit to humans and English language.

The Cochrane Library 16th April 2012: ((kawasaki disease):ti,ab,kw OR MeSH descriptor Mucocutaneous Lymph Node Syndrome explode all trees) AND MeSH descriptor BCG Vaccine.

Search Outcome

Twenty-four unique papers were found in Medline/Embase in English of which most were case reports. No relevant papers were found in the Cochrane Library. One paper offered the best evidence and this is summarised in the table

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Uehara et al,
2010
Japan
15,524 patients with Kawasaki disease and a history of BCG vaccination.Nationwide epidemiologic survey.Proportion of patients with Kawasaki disease who also had BCG site redness or crust formation49.9% of all patients with Kawasaki had BCG site redness and crust formation

70% of patients ages between 3 and 20 months had BCG site redness and crust formation
Study only in Japanese patients.

Comment(s)

There is only one large study in English which adequately answers this question all other relevant reports being case studies or small case series. Uehara et al show that particularly in children age 320 months BCG site redness or crust formation was frequently associated with Kawasaki disease. They also showed that the prevalence of BCG site changes was greater than that of cervical lymphadenopathy. The sensitivity of BCG skin changes in Kawasaki disease was 49.9%, however there is no data available to allow calculation of specificity or predictive value.

Clinical Bottom Line

In patients with suspected Kawasaki's disease in areas of high BCG vaccine uptake, BCG site skin changes may help in suggesting that a diagnosis of Kawasaki disease should be considered.

References

  1. Uehara R; Igarashi H; Yashiro M et al. Kawasaki Disease Patients With Redness or Crust Formation at the Bacille Calmette-Guerin Inoculation Site Pediatric Infectious Disease Journal 2010;29:4303.