DisseminatedMycobacterium BovisInfection Complicating Intravesical BCG Instillation for the Treatment of Superficial Transitional Cell Carcinoma of the Bladder

Abstract

BACKGROUNDIntravesical instillation of Bacillus Calmette–Guérin (BCG) remains a first-line treatment for superficial transitional cell carcinoma of the bladder. Although its use is relatively safe, severe complications such as granulomatous hepatitis, osteomyelitis, pneumonitis, and sepsis occur in few patients. Complications of intravesical instillation of BCG can be local or systemic, with early or late presentation.CASE PRESENTATIONHere, we report an 88-year-old man who developed fever, rigors, and episodes of syncope following fourth intravesical BCG instillation for the treatment of superficial transitional cell carcinoma of the bladder. Pancytopenia, disseminated intravascular coagulation, ground glass appearance on computerized tomography of the chest scan in addition to multiple bone marrow granulomas, suggested the diagnosis of disseminated BCG infection. All these features recovered on antituberculosis treatment.CONCLUSIONOur case study highlights the importance of early recognition and prompt treatment of patients with disseminated BCG infection following intravesical instillation. Although isolation of mycobacterium is desirable to make the diagnosis, it is not unusual to have negative smears and cultures and this should not be used to dismiss the possibility of BCG infection.

Vertebral Osteomyelitis Secondary to Bacillus Calmette-Guérin Instillation Therapy for Transitional Cell Carcinoma In Situ

“…An important risk factor is trauma to the urothelial tissue [ 8 - 9 , 11 , 14 ]. Trauma could manifest as a result of TURBT, pre-existing urinary tract infection (UTI), bladder catheterization, aseptic cystitis, indeed any comorbid condition that could cause hematuria [ 14 ].…”

“…The potential for the use of microbial products for the treatment of cancer was first noted in the late 1800s and the utilization of intravesical BCG was initiated with its first successful use for treatment in 1976 [3]. Intravesical BCG therapy is now the standard of care for bladder cancer, especially in the post-TURBT setting [2][3][4][5][6][7][8][9][10]. The proposed mechanism of action for the attachment of live BCG proceeds via internalization into the abnormally proliferating transitional cells lining the bladder, causing an upregulation of gene expression, which leads to an increase in proinflammatory cytokine factors [3].…”

“…Osteomyelitis is a rare but serious systemic complication of intravesical BCG therapy [2][3][4][5][6][7][8][9][10][11]. Other deleterious systemic complications include spondylodiscitis, mycotic aortic aneurysm, and septic arthritis [7][8][9][10]. In addition, pulmonary tuberculosis, lymphocytic meningitis, arthritis, and tubulointerstitial nephritis have also been reported [11].…”

“…Local and systemic complications have indeed been associated with it, although rarely, including (in descending order of prevalence) fever, hematuria, granulomatous prostatitis, pneumonitis and hepatitis, arthralgia, rash, ureteral obstruction, epididymitis, contracted bladder, renal abscess, sepsis, and cytopenia [7]. Other toxic complications have also been reported, such as spondylitis, mycotic aortic aneurysm, spondylodiscitis, septic joints, sepsis, and osteomyelitis [4,[7][8][9][10]. Mackel et.…”

Granulomatous Hepatitis Following Intra-Vesical Instillation of Bacillus Calmette–Guérin for Treatment of Bladder Cancer

“…Although usually well tolerated, both local and systemic BCG-related complications may occur following instillation, with early (in a few hours) or late (in several months) presentation [ 2 , 3 ]. Local side effects are frequent (90%), and may include urinary frequency, cystitis, fever and haematuria [ 4 , 5 ].…”