Concurrent granulomatous hepatitis, pneumonitis and sepsis as a complication of intravesical BCG immunotherapy

Abstract

SUMMARYIntravesical administration of BCG is a relatively simple procedure used successfully in the treatment of superficial transitional cell carcinoma of the urinary bladder. It is usually well tolerated with few major side effects. The authors report the case of an 80-year-old man who presented with sepsis, jaundice, hepatic and pulmonary failure 10 days after his last BCG instillation therapy, that was attributed to concurrent granulomatous hepatitis and pneumonitis due to Mycobacterium bovis dissemination. In rare instances severe life-threatening complications occur in relation with BCG instillation immunotherapy that may involve multiple organs and have different presentations and require a high index of suspicion and clinical awareness in a wide range of medical specialties. BACKGROUND

Case Presentation: Lung Consolidation as Sequelae of BCG Sepsis After Combined Intravesical and Intraurethral BCG

“…The mechanism of subsequent BCGosis may be a combination of an infectious process by the attenuated Mycobacterium bovis , and a delayed hypersensitivity reaction (type IV) 4 . Pathologic findings of miliary BCG yield granulomas that are often negative for acid-fast bacteria, thus supporting the theory of a systemic BCG induced hypersensitivity reaction.…”

Hypersensitivity Reaction After Intravesical Bacille Calmette Guerin Administration For the Treatment of Bladder Carcinoma

“…The combination of these findings sug-gested multi-organ failure, similar to other reported cases. 3,7 The diagnosis of BCG hypersensitivity reaction in the presented case was based on histopathological liver and bone marrow findings, failure to identify Bacillus spp. microbiologically, and unresponsiveness to antituberculosis treatment.…”

“…2 Complications associated with BCG treatment include pneumonitis, hepatitis, sepsis, and multi-organ failure. [2][3][4][5][6] Herein we present a patient with a hypersensitivity reaction to BCG that progressed to multi-organ failure and chronic renal failure.…”

Liver and Bile Duct Infections

“…204 The liver shows noncaseating epithelioid granulomas, epithelioid giant cells, mild steatosis, hepatocyte necrosis, and portal inflammation. [205][206][207] Often, AFB phosphatase, and hepatomegaly. 195 The histopathologic findings range from numerous well-formed, nonnecrotizing granulomas with rare acid-fast organisms on Ziehl-Neelsen stain to less wellformed granulomas with large numbers of acid-fast organisms spilling out of the loose granulomas into nearby Kupffer cells ( Fig.…”