Pediatr Radiol (2016) 46:237–245

DOI 10.1007/s00247-015-3464-z

ORIGINAL ARTICLE

BCGitis and BCGosis in children with primary immunodeficiency

— imaging characteristics
Shai Shrot 1,2 & Galia Barkai 3 & Aviva Ben-Shlush 1 & Michalle Soudack 1,2

Received: 2 April 2015 / Revised: 29 June 2015 / Accepted: 1 September 2015 / Published online: 10 October 2015
# Springer-Verlag Berlin Heidelberg 2015

Abstract
Background When administered to an immune-compromised
patient, BCG (Bacille Calmette-Guérin) can cause disseminat-
ed and life-threatening infections.
Objective To describe the imaging findings in children with
primary immunodeficiency and BCG-related infections.
Materials and methods We reviewed the imaging findings of
children with primary immunodeficiency treated at a chil-
dren’s hospital during 2012–2014 with localized or dissemi-
nated BCG infection. Imaging modalities included US, CT
and radiography.
Results Nine children with primary immunodeficiency had
clinical signs of post-vaccination BCGitis; seven of these chil-
dren showed disseminated disease and two showed only re-
gional lesions with characteristic ipsilateral lymphadenopathy.
Overall, lymphadenopathy was the most prevalent feature
(n=8) and characteristically appeared as a ring-enhancing
hypodense (CT) or hypoechoic (US) lesion. Visceral involve-
ment with multiple abscesses appeared in the spleen (n=2),
* Shai Shrot
shaishrot@gmail.com
1
Department of Diagnostic Imaging, Sheba Medical Center,
Tel-Hashomer, 2 Sheba Road,
Ramat-Gan 52621, Israel
2
Sackler School of Medicine, Tel Aviv University,
Tel Aviv, Israel
3
Pediatric Infectious Diseases Unit, Safra Children’s Hospital,
Sheba Medical Center,
Tel-Hashomer, Israel
liver (n=1) and bones (n=1). All lesions regressed following
appropriate anti-tuberculosis treatment.
Conclusion BCG infection needs to be considered in children
with typical findings and with suspected primary
immunodeficiency.
Keywords Bacille Calmette-Guérin . Bone . Children .
Computed tomography . Infection . Liver .
Lymphadenopathy . Mycobacterium . Severe combined
immunodeficiency . Spleen . Ultrasound
Introduction
Bacille Calmette-Guérin (BCG) is a live attenuated vaccine
routinely given to neonates in regions where tuberculosis is
endemic because it protects against miliary tuberculosis and
tuberculous meningitis [1]. For most children, BCG vaccina-
tion is safe. However, infections with varying severity caused
by BCG have been reported. Purulent regional lymphadenitis,
also known as BCGitis, is most common [1–3] and is charac-
terized by local erythema accompanied by ipsilateral regional
lymph node enlargement [4]. Less common is disseminated
infection following BCG vaccination, or BCGosis. It usually
involves distant lymph nodes, bone, liver and spleen.
BCGosis has almost always been reported in immunized chil-
dren who have underlying congenital or acquired immunode-
ficiency disorders [2, 3, 5]. We describe the imaging charac-
teristics in children with localized or disseminated BCG infec-
tion who presented at a tertiary university hospital.
238
Materials and methods
Patients
Between January 2012 and December 2014, 10 children were
diagnosed with BCGitis or BCGosis at our institution. Nine of
them had imaging studies of their infections and these com-
prise the study cohort. Our hospital’s institutional review
board approved the retrospective viewing of the children’s
images and clinical records for the purposes of this study.
Imaging modalities
Radiography
All radiographs were taken with digital radiography
(Shimadzu UD150L; Shimadzu, Kyoto, Japan).
Ultrasound
All examinations were performed with an ACUSON S2000
unit (Siemens Healthcare, Erlangen, Germany) and a convex
2- to 6-MHz probe, a linear 5- to 14-MHz probe or a linear 4-
to 9-MHz probe.
Ultrasound
All CT studies were performed with conventional techniques
on a commercially available 64-slice or 128-slice MDCT sys-
tem (Discovery CT750 HD; GE Healthcare, Cleveland, OH;
or Brilliance iCT; Philips Healthcare, Best, the Netherlands).
Abdominal protocol included the following parameters: slice
width 1.5 mm, increment 1 mm, collimation 64×0.625, rota-
tion time 0.4 s, pitch 0.985, tube voltage 80–100 kV and tube
current 100–120 mAs (according to body weight, departmen-
tal guidelines and automatic exposure control). Intravenous
low osmolality nonionic iodinated contrast material (Iomeron
350, Iomeprol; Bracco ALTANA Pharma, Konstanz, Germa-
ny) 1.5 ml/kg to 2 ml/kg was administered at a flow rate of 1–
1.5 ml/s. Images were obtained 50–70 s following intravenous
contrast administration. Post-contrast scans were reformatted
in the coronal and sagittal planes (3x2-mm increment). Post-
contrast scans were obtained for head examinations, and typ-
ical parameters included slice width 2 mm, increment 2 mm,
collimation 64×0.625, rotation time 0.4 s, pitch 0.391, tube
voltage 100 kV and tube current 250 mAs (according to body
weight, departmental guidelines and automatic exposure
control).
Statistical analysis
Data are presented in a descriptive way. Continuous parame-
ters are presented as mean±standard deviation.
Pediatr Radiol (2016) 46:237–245
Results
Clinical and laboratory characteristics
Nine children were identified. They had all been vaccinat-
ed with BCG at age ≤30 days. Age of presentation was 13
±9 months (range 2–29 months). All children were diag-
nosed with severe combined immunodeficiency. BCGosis
occurred in seven children, with lymphadenopathy the
most common presentation, seen in six of these. Isolated
localized infection (BCGitis), with or without localized
axillary lymphadenopathy was present in two children. Os-
seous involvement was found in one child. Seven children
had biopsies and cultures all positive for Mycobacterium
bovis. Biopsy sites included cutaneous lesions (n=3) and
enlarged axillary lymph nodes (n=4). Diagnosis was based
on clinical findings (involvement of injection site) in two
children. Demographic and clinical data are summarized in
Table 1.
Imaging findings
Lymphadenopathy
Lymphadenopathy was the most common finding and oc-
curred in eight of the nine children. The largest lymph
nodes measured 2.5 cm in long axis. Anatomical distribu-
tion of lymphadenopathy was as follows: axillary (n=6),
retroperitoneal (n=3), mesenteric (n=2), inguinal (n=2),
cervical (n=1) and mediastinal (n=1). On US the lymph
nodes were well-defined, round with hypoechoic to an-
echoic echotexture and absent normal echogenic hilum
(Fig. 1). Following treatment, lymphadenopathy de-
creased in size. In children with follow-up imaging stud-
ies (n=4), the echotexture changed over time, progressing
from hypoechoic to heterogeneous with anechoic areas
and ending in hyperechoic with echogenic foci compatible
with calcifications (Fig. 2). This pattern was seen both in
the axilla and in the porta hepatis. The surrounding soft
tissues had increased echogenicity. Color Doppler showed
deviated vessels and loss of normal arborization. In-
creased vascularity was noted surrounding the lymph
nodes.
On CT we noted two patterns for the thoracic and
abdominal lymph nodes: (1) hypodense with ring en-
hancement and (2) hypodense with hyperdense hilum,
central or displaced, and peripheral ring enhancement.
Both patterns were present in the same study. In one
child the mesenteric nodes coalesced, forming a large
hypodense mass-like lesion that caused intestinal ob-
struction (Fig. 3). None of the children had a follow-
up CT study.
 Table 1 Demographic and clinical features of study population

Patient Age at Gender Acid fast Sampling Type of bone marrow Clinical involvement Response to Imaging modalities
number presentation culture site for immunodeficiency transplantation multidrug anti- employed
(months) culture tuberculosis
treatment

1 8 F Positive Axilla SCID Yes Bones (skull, tibia, hand), spleen, axillary LN, + (imaging) CT, US, radiography
subcutaneous nodules
Pediatr Radiol (2016) 46:237–245

2 9 F Positive Axilla SCID Yes Axillary and retropritoneum LN + (imaging) US

3 8 F Positive Skin SCID No Liver, axillary, retroperitoneal and mesentery LN No follow-up US, CT
4 9 M Positive Skin SCID Yes Axillary LN, spleen, subcutaneous nodules + (imaging) US, CT
5 15 M Positive Skin SCID Yes Injection site + (clinical) -
6 14 M Positive Axilla SCID No Axillary, cervical and inguinal LN + (clinical) US
7 29 M Not done - SCID Yes Injection site, axillary and inguinal LN + (imaging) US
8 25 F Positive Axilla Under investigation No Axillary, mediastinal, retroperitoneal and mesenteric LN No follow-up CT, US
9 2 M Not done SCID Yes Injection site and axillary LN + (clinical) US

LN lymph node, SCID severe combined immunodeficiency

Liver

were not obtained.

hypovascular. BCG Bacille Calmette-Guérin

demonstrated multiple lesions of variable sizes, up to ap-

venous phase (Fig. 4). Follow-up CT studies of the lesions

On CT the lesions were hypodense during the portal-
Hepatic lesions occurred in one child. Both CT and US
Fig. 1 BCGitis manifesting in the axilla in a 9-month-old girl (Pt #2 in
Table 1). Transverse (a) and longitudinal (b) US images show enlarged
239

and the larger lesions had well-defined borders (Fig. 4).

proximately 18 mm. On US the lesions were hypoechoic,
hypo- to anechoic enlarged lymph nodes (arrows). Note the tract from the

with color Doppler shows that the abnormal lymph nodes (arrows) are
lymph node conglomerate to skin (dashed arrow in a). c Longitudinal US
240
Fig. 2 BCGosis manifesting as abdominal lymphadenopathy (Pt #1 in
Table 1). a First US examination at 9 months old shows enlarged
hypoechoic periportal lymph nodes (arrows). b On follow-up US after
6 months of anti-tuberculosis treatment the echotexture of the enlarged
periportal lymph node has become heterogeneous (arrow). c Four months
later the enlarged lymph node (arrow) has punctate echogenic foci, most
likely representing calcification. BCG Bacille Calmette-Guérin
Spleen
Splenic lesions (n = 2) were multiple and less than
5 mm at presentation on both CT and US. On CT
they were hypodense on the portal venous phase and
on US they were hypoechoic (Fig. 5). One child had
serial follow-up US scans, which showed simultaneous
increase in size and decrease in number over time.
Pediatr Radiol (2016) 46:237–245
Fig. 3 Disseminated BCGosis in a 2-year-old boy (Pt #8 in Table 1). a
Axial post-contrast CT of the upper chest shows diffuse ring-enhancing
lymphadenopathy (arrows) involving both axillae. b Axial post-contrast
CT image of the abdomen demonstrates enlarged retroperitoneal and
mesenteric lymph nodes (arrows). c Coronal reformat of post-contrast
CT shows small-bowel pseudo-obstruction with dilated small-bowel
loops (dashed arrow). Also note the bilateral enlarged hypodense
inguinal lymphadenopathy (arrows), some nodes with prominent
enhancing hilum. BCG Bacille Calmette-Guérin
After several months of treatment the lesions disap-
peared (Fig. 5).
Pediatr Radiol (2016) 46:237–245
Fig. 4 Disseminated BCGosis with liver involvement in an 8-month-old
girl (Pt #3 in Table 1). a Transverse US scan of the liver demonstrates
heterogeneous echogenicity of the liver with ill-defined hypoechoic
lesions (arrows). b Axial post-contrast CT image of the abdomen
shows hypodense hepatic lesions (arrows) with hypodense celiac
lymphadenopathy (arrowheads). BCG Bacille Calmette-Guérin
Bone
Skeletal involvement occurred in one child and involved the
hands, arms, legs and orbit (Fig. 6). The first lesion detected
by radiography occurred in the proximal phalanx of a finger
with dactylitis and showed a slightly expansile area of cortical
irregularity with a periosteal reaction. It further evolved into a
sizably expansile lytic lesion with well-defined borders. As
this evolvement took place new lytic lesions appeared in the
3rd metacarpal and the middle phalanx of the 4th finger in the
same hand. During the course of treatment lytic expansile
lesions were documented in the right distal radius and tibia,
all expansile with well-defined borders and cortical thinning.
The orbital lesion had cortical disruption and a periosteal re-
action (Fig. 6).
Subcutaneous nodules (n=2)
On radiograph these appeared as a soft-tissue density adja-
cent to the muscles (Fig. 7). On US they were well-defined
round or oval hypoechoic lesions with surrounding
241
hyperechogenicity and hyperemia. The center was anecho-
ic, compatible with liquefaction. On CT, enhancing multi-
ple small nodules were noted in subcutaneous tissue
(Fig. 7).
Discussion
BCG vaccination effectively protects against severe tubercu-
lous infections [1] and therefore is recommended by the World
Health Organization in communities endemic for tuberculosis
[6]. In Israel, all infants born in the West Bank or Gaza are
vaccinated with BCG during the first month of life [7].
Although BCG vaccines are considered safe in immune-
competent children, complications do occur, mainly at the
vaccination site [8]. Awad [7] reported an average complica-
tion rate of 14.7/1,000 BCG immunized infants in Gaza Strip
(98% were lymphadenitis and the remaining were abscess and
ulceration at the BCG injection site). Disseminated BCG in-
fection (BCGosis) is a rare but potentially dangerous compli-
cation of BCG vaccine and almost always occurs in children
with immunodeficiency disorders [9]. The frequency of
BCGosis is estimated to be 0.59 per 1 million vaccinated
children [10].
Immunodeficiency can be acquired or congenital. Frequen-
cy of primary immunodeficiency syndromes in Israel, i.e. con-
genital immunodeficiency, is 1–10:100,000 live births [11].
Primary immunodeficiency syndromes are usually not known
at birth and are characterized by increased susceptibility to
severe infections with various types of pathogens. All of the
children in our cohort had severe combined immunodeficien-
cy, which results from the impaired development of functional
T cells and B cells caused by various genetic mutations. Se-
vere combined immunodeficiency is thought to be the most
severe form of primary immunodeficiency. Our findings are
consistent with previous reports that suggest that the immuno-
logical condition of children is an important factor in post-
BCG vaccine infections. Norouzi et al. [2] reported that out
of 158 patients with BCGosis, 120 had immunodeficiency
disease. In 1995, Casanova et al. [12] reviewed 121 published
cases of disseminated BCG infections. They found 61 cases of
definitive immunodeficiency disease: 45 were severe com-
bined immunodeficiency disease, 11 were chronic granuloma-
tous disease, 4 were acquired immunodeficiency syndrome
and 1 had complete DiGeorge syndrome [12]. Of 74 con-
firmed cases of BCG infections reported from China, 32 chil-
dren (43.2%) had definitive primary immunodeficiency dis-
eases; however in this series chronic granulomatous disease
was the most common primary immunodeficiency [5].
Compatible with previous reports, lymphadenopathy,
whether regional (i.e. near vaccination site) or disseminated,
was the most common presentation of BCG infection in all
our patients [4, 5].
242 Pediatr Radiol (2016) 46:237–245

Fig. 5 Abdominal BCGosis with

splenic involvement in an infant
girl (Pt #1 in Table 1). a Axial
post-contrast CT scan performed
upon admission at age 9 months
shows multiple small hypodense
splenic lesions (arrows). b
Longitudinal US with high-
resolution linear transducer
demonstrates corresponding
hypoechoic lesions (arrows). c
Longitudinal US of the spleen
6 months following initiation of
anti-tuberculosis treatment
demonstrates coalescence of
some of the splenic lesions, which
have become heterogeneous. d
Longitudinal US of the spleen
18 months after initial
presentation demonstrates spleen
with normal echotexture. BCG
Bacille Calmette-Guérin

On US, enlarged lymph nodes were hypoechoic or anecho-
ic centrally, probably depending on the degree of caseation.
When the lymph nodes coalesced, a multilocular appearance
could be seen (Fig. 3). Following treatment, calcifications
were noted in some of the lymph nodes. These findings are
similar to the lymphadenopathy of tuberculosis [13, 14].
Although characteristic for mycobacterium infections, the
hypoechoic pattern of echogenicity in lymph nodes is a non-
specific sign. Both normal and reactive nodes are predomi-
nantly hypoechoic when compared with the adjacent muscles.
The sonographic appearance of lymphoma can be variable,
but hypoechoic or anechoic lymph nodes are typical. Metasta-
tic lymph nodes are also predominantly hypoechoic relative to
the adjacent musculature. Intranodal necrosis can be found in
both metastatic- and mycobacteria-involved nodes, and re-
gardless of nodal size the presence of intranodal necrosis
should be considered pathological [15]. Lymphomatous nodes
seldom show cystic necrosis unless the patient has had radia-
tion therapy or chemotherapy [16].
On post-contrast CT examinations the enlarged lymph
nodes were usually hypodense with rim enhancement, in both
the chest and the abdomen. The differential diagnosis of low-
density lymphadenopathy includes tuberculosis and
nontuberculous mycobacterium infections, lymphoma, meta-
static disease, fungal infections, Crohn disease, celiac sprue,
Whipple disease and Castleman disease [13]. The most char-
acteristic appearance of tuberculosis lymphadenopathy is
ring-enhancing lymph nodes with a low-density center
[13, 17]. However most children with tuberculosis have pul-
monary pathology. All of our patients had normal chest radio-
graphs and, when available, normal lungs on CT, decreasing
the likelihood of primary tuberculosis.
In children younger than 5 years tuberculosis frequently
manifests as generalized lymphadenopathy, 65–75% of which
is thoracic and mediastinal, reflecting the lymphatic drainage
of the involved organs [18]. Abdominal lymphadenopathy in
children with tuberculosis typically involves the porta hepatis
and the para-aortic region but can also involve the mesenteric
nodes, with typical fanning out of the vessels and marginali-
zation of the bowel loops [17]. Ring enhancement with central
hypodensity is also characteristic of nontuberculous mycobac-
terial lymphadenitis, which is sometimes generalized and dis-
seminated in immune-compromised children [19]. Pursner
et al. [20] described massive retroperitoneal and mesenteric
lymph node enlargement in children with human immunode-
ficiency virus (HIV) who develop Mycobacterium avium–
intracellulare complex infection [20]. Lymphoma is more
likely to affect primarily para-aortic nodes, and the nodes are
commonly larger than in tuberculous lymphadenitis [21].
In the presence of a known primary malignancy, enlarged
abdominal nodes are more likely to be nodal metastases.
The two patterns noted in this study for the thoracic and
abdominal lymph nodes most likely represent different stages
of caseation. Although pre-contrast scans were not obtained
Pediatr Radiol (2016) 46:237–245 243

Fig. 6 Disseminated BCGosis

and skeletal involvement in an
infant boy (Pt #1 in Table 1). a
Anteroposterior hand radiograph
at 9 months old shows expansile
lytic lesions (arrows) with
periosteal reaction in the 3rd
metacarpal bone and proximal
phalanx of 4th finger. b
Anteroposterior radiograph of the
right calf demonstrates a large
lytic lesion in the metadiaphysis
of distal tibia (asterisk). Note
thick periosteal reactions (arrow).
c Anteroposterior calf radiograph
after 6 months of anti-tuberculosis
treatment shows partial regression
of the tibial lesion. Axial (d) and
coronal (e) reformat of post-
contrast head CT scan
demonstrate a lytic lesion (arrow)
in the left maxillary bone with an
accompanying ring-enhancing
soft-tissue component (dashed
arrow). BCG Bacille Calmette-
Guérin

for the thoracic and abdominal CT scans, we assume that the
hyperdense hilum is caused by increased vascularity and rep-
resents an active phase prior to caseation.
When treated, there is usually slow resolution of the
lymphadenopathy in BCG-related infections. Because evalu-
ation of response to antibiotic treatment is generally assessed
clinically [22], there are only sparse descriptions in the litera-
ture regarding the radiologic resolution of mycobacterial dis-
ease. In our cohort, serial sonographic studies were used to
document this resolution, from caseating necrosis to calcified
lymph nodes (Fig. 2). In tuberculous infections, worsening of
radiographic findings in chest imaging or enlargement of
nodes might be observed in up to one-third of patients receiv-
ing appropriate therapy [22, 23]. Similarly, transient enlarge-
ment of BCGosis lesions (pseudo-progression) was observed
in a minority of our patients (Fig. 5).
The most common hepato–splenic involvement in our pa-
tients was numerous small nodules, at times barely visualized
on CT or US. High-frequency US transducers were needed for
adequate spatial resolution. Low-density multifocal lesions is
the most common CT finding in patients with hepato–splenic
tuberculosis [17]. People with tuberculosis, however, might
also have inflammatory conglomerations of bowel loops with
adherent omentum and adjacent lymphadenopathy [17]. None
of our patients showed inflammatory involvement of bowel
loops or of the mesentery. In immune-compromised children,
multiple small hypoechoeic lesions on sonography or
hypodense lesions on CT scans (best seen following intrave-
nous contrast injection at the porto-venous phase) can be a
manifestation of fungal abscesses (e.g., candidiasis),
Pneumocystis jirovecii infection or sarcoidosis [24]. Com-
monly these opportunistic infections share a nonspecific
clinical presentation with unexplained fever and
hepatosplenomegaly. A nonspecific attenuated granulomatous
reaction is usually seen histologically and special stains and
fungal cultures are generally required for specific diagnosis.
BCG osteomyelitis is indistinguishable radiographically
from tuberculous osteomyelitis. These lesions usually occur
in the epiphysis and metaphysis and can cross the growth plate
[25]. As the focus of infection enlarges, caseation occurs with
subsequent destruction of bone trabeculae and cortical bone in
a later stage of the disease. The best-known form of
244
Fig. 7 Subcutaneous involvement in BCGosis in a 12-month-old girl. A
subcutaneous lesion (arrows) is seen at the wrist on longitudinal gray-
scale US (a) (Pt #1 in Table 1), with peripheral hyperemia on color
Doppler US (b) (Pt #1 in Table 1). c Abdominal–pelvic post-contrast
CT in a 9-month-old boy shows multiple subcutaneous nodules
(arrows) (Pt #4 in Table 1). BCG Bacille Calmette-Guérin
tuberculous osteitis, which was demonstrated in one of our
patients, was dactylitis, an infection of the short tubular bones
of the hands and feet. Soft-tissue swelling is associated around
the affected bone, most frequently a metacarpal or proximal
phalanx [25].
Conclusion
The hallmark of disseminated BCG infection in our cohort of
children with primary immunodeficiency was lymphadenop-
athy with or without visceral involvement. Because the radio-
logic pattern is very similar to that of tuberculosis, effective
Pediatr Radiol (2016) 46:237–245
collaboration between clinicians and radiologists is crucial for
early recognition of these infections.
Conflicts of interest None
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