Hepatitis in Disseminated Bacillus Calmette-Guérin Infection

Abstract

Local immunotherapy with an attenuated live strain of Mycobacterium bovis, bacillus Calmette-Guérin (BCG), is an effective and frequently used treatment for in situ transitional cell carcinoma (TCC) of the bladder. Success rates are high, and serious side effects are infrequent but can affect every organ system. A 79-year-old patient with recently diagnosed TCC who was treated with intravesical BCG for a recurrence after initial surgical treatment is reported. After unsuccessful attempts at bladder catheterization with the creation of a false passage for his third treatment, BCG was instilled via a suprapubic catheter the same day and again a week later. Two weeks after the third BCG instillation, the patient presented with profound lethargy and weakness to the point of not being able to get up out of a chair. He was febrile, anorexic, icteric and had hepatosplenomegaly. Disseminated BCG infection was suspected on the basis of history, clinical examination and a liver biopsy that showed noncaseating granulomatous hepatitis. Empirical treatment was started with antituberculous combination therapy. A short course of an oral corticosteroid was given. Clinical improvement was marked and sustained so that the patient could be discharged home for the full six-month course of his treatment. Disseminated BCG infection with granulomatous hepatitis can be severe and life-threatening in cases where a large intravascular inoculum of BCG may have been given inadvertently.

Bacillus Calmette-Guérin (BCG) Infection Following Intravesical BCG Administration as Adjunctive Therapy For Bladder Cancer

“…Therefore, we included a total of 201 articles comprising 271 cases of BCG infection after intravesical instillation published since 1975. 1 – 14 , 17 – 19 , 21 – 31 , 33 – 39 , 41 – 49 , 51 – 71 , 73 – 80 , 82 – 84 , 87 – 97 , 99 , 101 , 102 , 104 , 105 , 107 – 119 , 121 – 138 , 140 – 151 , 153 – 168 , 170 , 171 , 173 – 180 , 182 – 189 , 192 , 193 , 195 – 202 , 205 – 208 , 210 – 214 , 218 , 219 , 221 – 223 , 225 – 232 Of these, 170 were individually detailed cases, and 31 were summarized in reports containing 2–13 cases. All data shown here were extracted from these case reports and case series, but occasionally articles lacked relevant clinical or microbiologic data.…”

Sepsis und Multiorganversagen nach BCG-Instillation bei Blasenkarzinom

“…Schwere systemische Komplikationen wie Miliartuberkulose, Hepatitis, Pneumonie oder Sepsis finden sich gehäuft nach schwieriger oder traumatischer Katheterisierung [3,5,18]. Zugang der Mykobakterien zur Blutbahn und Immunsuppression sind die Hauptrisikofaktoren für die Entwicklung schwerer, systemischer Komplikationen.…”

“…In dieser Rubrik sind in der Zeitschrift "Der Internist" zuletzt folgende themenverwandte Fallberichte erschienen: nach BCG-Instillation [6,18]. 14 Tage nach Beginn der Therapie waren die Leberwerte stabil, und Isoniazid wurde hinzugefügt.…”

Management of hepatic granulomatous tuberculosis complicating intravesical BCG for superficial bladder cancer

“…Based on histological diagnoses from liver biopsies, the liver has been reported as a potential site of disseminated disease, 11 but tissue culture of Mycobacterium bovis BCG, which is the ultimate proof of the disease after intravesical BCG has not been described in the literature. Lamm and colleagues 4,6 reported a combined incidence of pneumonitis and hepatitis of 0.9%, but 7 out of 46 (15%) severe systemic complications had indirect proof of disseminated BCG with granulomatous lesions on biopsy and were considered diagnostic.…”