Local Bacillus Calmette-Guérin (BCG) immunotherapy is an effective and widely used treatment for superficial bladder carcinoma. Local side effects are frequent, whereas systemic side effects are rare, but more serious. Systemic BCG infection as a life-threatening complication of intravesical BCG instillation should be suspected in any patient who presents with persistent fever after BCG instillation for bladder cancer. A 62-year-old patient had been treated with 6 intravesical BCG instillations for recurrent, multifocal bladder carcinoma. 4 weeks after the last instillation, he presented with fever, malaise and scleral icterus. Laboratory tests revealed abnormal liver function tests, panzytopenia and signs of coagulation disorder. Bone marrow biopsy and liver biopsy showed noncaseating granulomas. Systemic BCG infection was suspected and antituberculous therapy combined with steroids was started. The patient developed severe sepsis and suffered from multiple organ failure. Despite partial improvement, the course was complicated by intracranial sinus thrombosis, and the patient died two month after admission.
Background
Bronchoscopic lung volume reduction (BLVR) with endobronchial valves (EBV) can be a successful treatment for end-stage emphysema patients. The reduction of hyperinflation enhances ventilatory mechanics and diaphragm function. Understanding predictors for treatment success is crucial for further improvements.
Purpose
The aim of this study was to assess the effect of the target lobe volume reduction (TLVR) in relation to the ipsilateral lung volume reduction (ILVR), affected by the compensatory expansion of the adjacent lobe, on the outcome after BLVR with valves.
Patients and Methods
The volumetric relationship of ILVR% to TLVR%, addressed as
R
eduction R
atio
(
R
), was recorded in 82 patients and compared to changes in lung function, physical performance and quality of life. A small value for
R
implies a relatively low volume reduction of the ipsilateral lung (ILVR) compared to the volume reduction of the target lobe (TLVR). Additionally, the minimal clinically important difference (MCID) for
R
was calculated.
Results
Patients with a smaller
Reduction Ratio
(
R
<0.2) showed minor improvements at the 3 months follow-up compared to patients with
R
≥0.2 (mean changes of 39 mL (5.8%), –395 mL (–4.9%) and 96 mL (7.1%) versus 231 mL (33%), –1235 mL (–20%) and 425 mL (29%) in the forced expiratory volume in 1s (FEV
1
), residual volume (RV) and inspiratory vital capacity (IVC), respectively, and –3 m and 0 points versus 20.4 m and –3.4 points in the 6-minute-walking-distance (6MWD) and COPD assessment test (CAT) score respectively). With a combined value of 0.185, a MCID for
R
was calculated with established anchors (FEV
1
, RV, and 6MWD) for emphysema patients.
Conclusion
Extensive compensatory hyperinflation of the adjacent non-treated lobe after BLVR results in decreased ILVR, which is responsible for a lack of meaningful improvements in ventilatory mechanics and clinical outcome, despite technically successful lobe volume reduction.
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