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Year : 1955  |  Volume : 3  |  Issue : 3  |  Page : 49-53

Phlyctenular ophthalmia following B.C.G. vaccination

Department of Ophthalmology, Patna Medical College, Patna, India

Correspondence Address:
P N Mukherjee
Department of Ophthalmology, Patna Medical College, Patna
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How to cite this article:
Mukherjee P N. Phlyctenular ophthalmia following B.C.G. vaccination. Indian J Ophthalmol 1955;3:49-53

How to cite this URL:
Mukherjee P N. Phlyctenular ophthalmia following B.C.G. vaccination. Indian J Ophthalmol [serial online] 1955 [cited 2021 May 15];3:49-53. Available from: https://www.ijo.in/text.asp?1955/3/3/49/33579

Table 1

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Table 1

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Since the early nineteenth century tuberculosis (scrofulosis) has been held responsible for the causation of phlyctenular ophthalmia. Beer (1813), while classifying ocular diseases had grouped this condition under the term "Scrofulom Ophthalmia" in which he included all the ocular diseases known to be caused by a diathesis. Since then a vast amount of literature has accumulated in the experimental, pathological and clinical fields to support this view. Inspite of all these vigorous researches directed to establish a tubercular actiology of phylctenu­losis, tubercle bacilli have never been isolated, nor any characteristic histologic picture demonstrated in the lesions. This has led to the suggestion of allergy as an xtiologic factor of phlyctenulosis. Nowadays the consensus of opinion is that the ground is essentially prepared by tuberculo-toxin or the bacilli themselves by preparing a sensitised soil and the attack of phlyctenulosis indicates a local allergic reaction in an eye precipitated by various factors which may or may not be specific (Sorsby, 1942).

The precise mechanism as to how either the sensitised soil is prepared or the attack is precipitated is, as yet, not fully established. A skin-eye allergy is thought to exist. If the skin becomes hypersensitive to some bacterial protein the ocular epithelium shares it. Similarly if the cutaneous' hypersensitivity is reduced by desensitisation the eye also gets desensitised. Juliannele (cited by Lasky, 1932) demonstrated in rabbits such a special skin and eye hypersensitiveness to pneumo­cocci, not transferable from the sensitive to the normal animals. Derick and Swift (also cited by Lasky) had corresponding findings with streptococcus viridens. Lasky (1932) thought that this peculiar allergy entity depended in some way on the embryological derivation, the epidermis, the epithelium of the cornea and conjunctiva all being ectodermal.

That intra-cutaneous tuberculin injections can desensitise a hypersensitive eye is proved clinically by the encouraging results of tuberculin therapy in tuberculo-allergic conditions of the eye. This can be explained by assuming the special skin-eye allergy, established in cases of pneumococci by Julianelle and of streptococci by Derick & Swift, which can also hold good in the case of tubercle bacilli.

The reverse experiments of producing an allergic crisis in the eye by making a person artificially allergic to living tubercle bacilli has, perhaps, never been attempted due to obvious reasons. That such is possible is suggested by a few reports in the recent literature of Phlyctenular Ophthalmia-an accepted allergic crisis of the eye-following B.C.G. vaccination. Thus Damato (1951) reported 10 cases in which B.C.G. vaccination was followed by Phylctenular kerato-conjunctivitis. Tabone (1952) similarly recorded 17 cases of Phlyctenular disease following B.C.G. vaccination.

B.C.G. vaccination consists of introduction into the body of living tubercle bacilli of attenuated virulence. A bovine strain attenuated by prolonged growth on a Bile-Glycerol-Potato medium is used. The strain is usually designated B.C.G. after the name of Calmette-Guerin. Old tuberculin which does not con­tain the bacilli themselves, fails to evoke an active immunological response B.C.G. vaccine evokes a specific active immunological response and affords pro­tection against future tubercular infections.

  Personal Observations Top

An enquiry on the subject "The Role of Tubercular Allergy in Phlyctenular Ophthalmia" was undertaken by us at the P. W. Medical College, Patna, during the period 1952-54. A series of 145 cases of phlyctenular ophthalmia were investigated. During the course of these investigations 14 cases of phlyctenular disease following B.C.G. vaccination came under observation. The relevant features of these 14 cases are presented in the following table:


The allergic concept of phlyctenulosis, by now has been amply varified by workers in the experimental, clinical, laboratory and therapeutic fields (Papagna, 1935; Columba, 1935; Duke-Elder, 1938; Sorsby, 1942: Doggart, 1947; Mathieu, 1947; Lodi, 1947; Copolongo, 1950: Carneiro, 1950). There is also general agree­ment on the specifically tuberculosis nature of the initial hypersensitivity over which superadded specific or non-specific local precipitating factor or factors are supposed to act to bring about a phlyctenular attack.

The reason of selecting only the Mantoux-negative individuals for B.C.G. vaccination is that such persons are assumed never to have had a tubercular infection. Mantoux-positivity denotes a previous tubercular infection and is an indication of the immunity and/or allergy that the individual possesses. The development of immunity and allergy go hand in hand and which of these will predominate depends in a large measure on the resistance of the host. If a Mantoux-positive individual is vaccinated with B.C.G., not only will it serve no useful purpose but it may be harmful if the individual is already in a state of allergy, by precipitating an acute allergic crisis.

The appearance of phlyctenulx after B.C.G. vaccination must therefore entail the introduction of the same sensitizing agent on two successive occasions. As stated, a Mantoux test is first done and if negative a B.C.G. vaccination is carried out to promote immunity against tuberculosis.

Utmost caution and experience are therefore needed in interpreting the Mantoux test before vaccination with B.C-G. Unwarranted vaccination can preci­pitate an acute allergic crisis, i.e. phlectinulosis in the eye with glandular enlarge­largements, fever and other constitutional symptoms in the more severe cases.

In a mass-scale campaign like the "B.C.G." there is possibility of a not-so­correct interpretation of a "Mantoux" in an occasional instance and so the deve­lopment of phlyctenulx after B.C.G. vaccination can be understood in such cases.

An initial sensitization from any other allergen, (in which case Mantoux will be negative) also favours the development of phlyctenulm by the superimposition of some local, perhaps extraneous precipitating factor or factors which may be difficult to identify and which may operate coincidentally with B.C.G. vaccina­tion. In this case the B.C.G. vaccination may have a falsely apparent influence only or an indirect influence by lowering the vitality of the patient.

Looking at Table I one remarks the comparatively long interval between B.C.G. vaccination and the appearance of ocular and general symptoms. Only in one case the interval is 9 days. In this case, (10) the appearance of phlyctenulae and general symptoms are simultaneous, that is 9 days after vaccination. In the other cases the interval between vaccination and appearance of phlyctunulae is longer, anything from 2 to 12 months. In those cases where there have been general symptoms as well, like fever, cough, etc. these symptoms always seem to have preceded the appearance of phlyctenulae, suggesting that, either the ocular manifestation is a later one or B.C.G. vaccination creates a state of allergy within the person injected, which is made manifest by the appearance of phlyctenulae in the eye as a result of some local extraneous precipitating factor, as stated above. The latter assumption appears to be the more likely one. In case (10) with the simultaneous appearance of phlyctenulae and general symptoms 9 days after vaccination the vaccination itself may be the precipitating cause in a person already sensitized by any other allergen.

This study shows that in a few instances where the appearance of phlyctenulae follows B.C.G. vaccination it cannot be taken as avidence of danger of B.C.G. vaccination. At most it hypersensitizes certain patients to the proteins of the vaccine, like in the case of any other protective vaccination small-pox, typhoid, etc.

  Summary Top

In a study on "the Role of Tubercular Allergy in Phlyctenular Ophthalmia", 14 cases were met with in which the development of phlyctenulae could be attributed to B.C,G, vaccination. These have been studied and recorded.

The study suggests that the appearance of phlyctenulx is only a manifestation of hypersensitivity to the proteins of any protective vaccine and may not be con­sidered as a specific danger of B.C.G. vaccination.[17]

  References Top

Beer (1813) Lehre de Augenh., Vienna, 1, 58. (cited by Sorsby in 16.)   Back to cited text no. 1
Carneiro (1950). Brasil-Med., 64, 177. (Ref. Ophth. Lit., 4, Abs. 4749.)  Back to cited text no. 2
Columba (1935). Ann. di. Ottal., 64, 177. (Ref. Am. J. Ophth., 1935, 18, 1164.)   Back to cited text no. 3
Copolongo (1950), Boll. d'ocul., 29, 441. (Ref. Am. J. Ophth., 1951, 34, 480.)   Back to cited text no. 4
Damato (1951), Brit. J. Ophth., 35, 416.  Back to cited text no. 5
Doggart (1947), M. Press. 218, 275.  Back to cited text no. 6
Duke-Elder (1938). Text Book Book of Ophthalmology, Vol. 2, Henry Kimpton. London, p. 1686.  Back to cited text no. 7
Lasky (1932), Am. J. Ophth., 15, 725.  Back to cited text no. 8
Lodi (1947), Clin. Ped. Bologna 29, 358. (Ref. Ophth. Lit., 1. Abs. 3362.)  Back to cited text no. 9
Mackie & McCartney (1946). Handbook of Practical Bacteriology. E. & S. Living­stone, Edinburgh.  Back to cited text no. 10
Mathieu (1947), Rev. Med. de Liege, 2, 165. (Ref. Ophth. Lit., 1, Abs. 1210.)   Back to cited text no. 11
Papagno (1935), Ann. di. Ottal., 63, 288. (Ref. Am. J. Ophth.. 1935, 18, 789.)   Back to cited text no. 12
Sorsby & Benham .(1936), Proc. Roy. Soc. Med., 29, 955.   Back to cited text no. 13
Sorsby, Hamburger & Benham (1936), Trans. Ophth. Soc., U.K., 56, 63.   Back to cited text no. 14
Sorsby et al (1938), Trans. Ophth. Soc., U.K., 58, 173.   Back to cited text no. 15
Sorsby (1942), Brit. J. Ophth., 26, 159.  Back to cited text no. 16
Tabone (1952), Brit. Med. J., 1, 837.  Back to cited text no. 17


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