Mycobacterial Osteomyelitis of the Spine Following Intravesical BCG Therapy for Bladder Cancer

Abstract

Osteomyelitis is an infection of the bone that can involve the vertebral column. A rare cause of vertebral osteomyelitis is Mycobacterium bovis after intravesical Bacillus Calmette-Guerin (BCG) therapy for transitional cell carcinoma of the bladder. In this report, we describe the case of a 64-year-old male presenting with constitutional symptoms, progressive thoracic kyphosis, and intractable T11 and T12 radiculopathies over the proceeding six months. A CT scan revealed erosive, lytic changes of the T12 and L1 vertebrae with compression of the T12 vertebra. An MRI demonstrated T11-12 osteomyelitis with intervening discitis and extensive paraspinal enhancement with a corresponding hyperintensity on a short tau inversion recovery (STIR) sequence. A needle aspiration grew out Mycobacterial tuberculosis complex that was pansensitive to all antimicrobial agent therapies, except pyrazinamide on culture, a finding consistent with an M. bovis infection. The patient’s infection and neurologic compromise resolved after transthoracic T11-12 vertebrectomies with decompression of the spinal cord and nerve roots as well as T10-L1 instrumented fusion and protracted antimicrobial therapy. The epidemiology and natural history of M. bovis osteomyelitis are reviewed and the authors emphasize a mechanism of vertebral inoculation to explain the predilection of M. bovis osteomyelitis in males after intravesical BCG therapy.

Back pain following instillations of BCG for superficial bladder cancer is not a reactive complication: review of 30 Mycobacterium bovis BCG vertebral osteomyelitis cases

“…T12 to L4. Secondarily, as recently suggested [28], through the vertebral venous plexus (known as Batson's venous plexus). Once again, a venous spread of BCG does not explain thoracic osteomyelitis.…”

“…However, other distant infections are described in the literature, mostly vascular aneurysms in a recent literature review [43], but also disseminated infections also called BCGitis [44], small-vessel central nervous system vasculitis [45] and even nosocomial infections, including vertebral osteomyelitis [46]. Some risk factors of distant infections could be suggested: a traumatic catheterisation during instillation [5], haematuria, instillations in the few days around an urological trauma [28] (pelvic radiation, surgery, bladder resection), arterial catheterisation [13], and general immunosuppressive factor such as HIV infection.…”

Tuberculous Spondylitis Caused by Intravesical Bacillus Calmette-Guerin Therapy

“…Intravesical BCG therapy for the treatment of superficial bladder cancer has a low risk of extravesical complications, which are rare (5), but adverse effects such as cystitis, a fever, hematuria, prostatitis, arthralgias, and reactive arthritis are relatively common. The first study to mention tuberculous spondylitis caused by intravesical BCG therapy was reported in 1992, but only 13 cases related to intravesical BCG therapy for bladder cancer have been reported since (6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17) (Table). In most cases, BCG spondylitis develops several months after intravesical BCG therapy, while some cases may develop several years later, but the cause is unknown (13).…”

Mycobacteria Bovis osteomyelitis following intravesical BCG for bladder cancer

“…Since 1976, BCG has been administered intravesically to treat transitional cell carcinoma of the bladder, and has proven to be a safe and effective therapy for various carcinomas in situ [1] , [2] . It comes with potential side effects [3] , where serious reactions may occur in less than 5% of patients [2] .…”

“…Osteitis is rare following BCG immunization, occurring in less than 37 per 100,000 cases [2] . As of 2016 there were only 16 cases of vertebral osteomyelitis secondary to intravesical BCG reported in the English literature [1] . Venous translocation via the Batson plexus or hematogenous spread are postulated mechanisms for dissemination [1] .…”