Primary tuberculosis of glans penis after intravesical bacillus calmette guerin immunotherapy

Abstract

A 55-year-old male with carcinoma in situ of urinary bladder was treated with weekly intravesical injections of Bacillus Calmette Guerin (BCG) vaccine. Three days after the sixth injection, he developed low grade fever and multiple grouped punched out, 2-3 mm ulcers around meatus and corona glandis. In addition, multiple, firm, indurated, nontender papules and few deeper nodules were present on the proximal part of glans penis, along with bilateral enlarged, matted and nontender inguinal lymph nodes. There was no history suggestive of sexually transmitted diseases and high risk behavior. Chest X-ray was within normal limits, and Mantoux, Venereal Disease Research Laboratory (VDRL) and HIV antibody tests were negative. The biopsy from the penile ulcer revealed epithelioid cell granuloma with Langhans giant cells. Fine needle aspiration cytology from the lymph node also revealed epithelioid cell granuloma and acid fast bacilli on Ziehl Neelsen's stain. The tissue biopsy grew Mycobacterium tuberculosis. The BCG immunotherapy was stopped and patient was treated with four drug antitubercular therapy with isoniazid, rifampicin, ethambutol, and pyrazinamide in standard daily doses along with pyridoxine. The edema resolved and the ulcers started healing within 2 weeks, and at 6 weeks after starting antitubercular therapy almost complete healing occurred. To the best of our knowledge, we describe the first case of an Indian patient with BCG induced primary tuberculosis of penis after immunotherapy for carcinoma urinary bladder and review the previously described cases to increase awareness of this condition in dermatologists and venereologists.

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.…”

Penile tuberculosis following intravesical Bacille Calmette-Guérin immunotherapy

“…[45] In our case, papules were on the surface of the glans. This suggests that BCG might come in direct contact with the involved area either by inadvertent spillage or from voided urine.…”

Tuberculosis of the glans penis healing with meatal stenosis

“…Primary glans tuberculosis may be acquired by sexual contact with patient suffering from genital tuberculosis or contamination from infected clothings 1. Primary tuberculosis of glans has also been reported after intravesical BCG immunotherapy for bladder cancer 3. Tuberculosis of glans presents as superficial lesion, which may be difficult to differentiate from malignant tumours 1.…”