Severe pneumonia after intravesical BCG instillation in a patient with invasive bladder cancer: case report and literature review

Caramori, Gaetano; Artioli, Denise; Ferrara, Giovanni; Cazzuffi, Riccardo; Pasquini, C.; Libanore, Marco; Guardigni, Viola; Guzzinati, Ippolito; Contoli, Marco; Rossi, R; Rinaldi, Rosa; Contini, Carlo; Papi, Alberto

doi:10.4081/monaldi.2013.109

Cited by 5 publications

(11 citation statements)

References 15 publications

(16 reference statements)

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“…The reason for this striking male predominance is unclear, but this trend has also been observed in several previous series. 16,17 The time between intravesical BCG instillation and development of symptoms varies widely, occurring as soon as a few hours after traumatic cystoscopy, 8,15 or long after completion of treatment, as our cases illustrate. Granulomas are almost always seen, regardless of the organ involved, and are usually poorly formed, nonnecrotizing, and randomly distributed, but occasional cases may show caseating necrosis.…”

Section: Discussionmentioning

confidence: 84%

Histopathology of Disseminated Mycobacterium bovis Infection Complicating Intravesical BCG Immunotherapy for Urothelial Carcinoma

et al. 2015

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Intravesical instillation of Bacillus Calmette-Guérin (BCG) is a mainstay of adjunctive therapy for superficial bladder cancer. Disseminated BCG infection ("BCG-osis") after this therapy is rare and potentially life-threatening; only isolated case reports detail the histopathologic findings thereof, few of which had a diagnosis confirmed by molecular testing. We report 3 additional cases of BCG-osis complicating BCG therapy, all confirmed by cultures and molecular assays, including the first cases of wedge biopsy-confirmed BCG pneumonia and BCG olecranon bursitis. When suggested by a relevant clinical history, recognition of randomly distributed granulomas in any organ should prompt consideration of BCG-osis and liberal performance of AFB stains, aided by targeted molecular assays. Physicians should maintain a high index of suspicion when miliary infiltrates arise after intravesical BCG instillation, and close multidisciplinary communication is essential. Pathologist awareness of this rare cause of granulomatous inflammation aids recognition of BCG-osis and facilitates prompt initiation of antimycobacterial therapy.

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Section: Discussionmentioning

confidence: 84%

Histopathology of Disseminated Mycobacterium bovis Infection Complicating Intravesical BCG Immunotherapy for Urothelial Carcinoma

et al. 2015

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“…Only mild systemic symptoms, such as fever, malaise, and chills, as well as local symptoms of lower urinary tract are generally reported that usually resolve within a few hours or days. From scientific literature, we have noticed at least 37 cases of miliary pulmonary tubercolosis related to BCG instillation (4, 11-12-13-14-15-16-17-18-19-20-21-22-23-24-25-26-27-28-29-30-31-32-33-34-35-36-37-38-39-40-41-42-43-44-45-46). We know that pulmonary complications could be of two kinds: hypersensitivity and mycobacterial pneumonia.…”

Section: Discussionmentioning

confidence: 99%

Intravesical BCG Therapy as Cause of Miliary Pulmonary Tuberculosis

et al. 2015

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Immunotherapy with intravesical bacillus Calmette-Guérin (BCG) is considered the most effective adjuvant to endoscopic resection of bladder urothelial carcinoma in the therapeutic management of non-muscle invasive (NMIBC) at intermediate and high risk of recurrence and progression (pTa - pT1 and high-grade carcinoma in situ, CIS). Despite its proven efficacy, this type of treatment can determine local and systemic side effects of moderate or severe gravity, with the histological diagnosis of epithelioid granulomas in different organs, even in the absence of microbiological positivity of BCG. The immunotherapy with BCG is usually well tolerated and the virulence of the attenuated BCG is very low in immuno-competent patients, although only 16% of patients are able to receive all the instillations of the maintenance period (3 years) of treatment provided by the protocols, precisely because of side effects. Minor side effects usually resolve within a few hours or days. They develop in 3-5% of patients and usually consist of local infectious complications. Manifestations of BCG dissemination, such as vascular and ocular complications, are much less common, while BCG-disseminated infections, with granulomatous pneumonia or hepatitis present, are quite rare, representing 0.5-2% of the complications recorded. We present the clinical case of granulomatous lung and possibly liver infection caused by BCG in a patient aged 56 years being treated for several weeks with intravesical BCG for NIMBC pT1 high grade associated with CIS.

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“…Chest imaging of these cases revealed a military pattern (n = 12), bilateral pulmonary opacities (n = 2), and reticulonodular pattern (n = 1). However, the pleural effusion was not included [16]. Although BCG-induced parenchymal infiltration with a modest homolateral pleural reaction was observed in a patient with COPD and a history of previous tuberculosis in one case report, the presence of pleural effusion and details of the “pleural reaction” were not described [17].…”

Section: Discussionmentioning

confidence: 99%

BCG-induced pneumonitis with lymphocytic pleurisy in the absence of elevated KL-6

et al. 2014

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BackgroundPneumonitis is a rare complication of bacillus Calmette-Guerin (BCG) immunotherapy seen in patients with urothelial cancer following the repeated administration of BCG. However, no case of BCG-induced pleurisy has been reported.Case presentationWe here report the first case of pneumonitis with lymphocytic pleurisy following bacillus Calmette-Guerin (BCG) immunotherapy. Although marked T helper cell alveolitis was found by bronchoalveolar lavage and transbronchial biopsies, no acid-fast bacillus could be identified in recovered BALF or pleural effusion. The lymphocyte stimulation test of BCG was strongly positive. However, levels of serum and bronchoalveolar lavage fluid KL-6, a useful marker for hypersensitivity pneumonitis (HP), were within normal ranges.ConclusionWe speculate that the pathogenesis of our case may be a hypersensitive reaction to the proteic component of BCG entering the lung and pleural space, which is different from the etiology of the common type of HP.

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Severe pneumonia after intravesical BCG instillation in a patient with invasive bladder cancer: case report and literature review

Cited by 5 publications

References 15 publications

Histopathology of Disseminated Mycobacterium bovis Infection Complicating Intravesical BCG Immunotherapy for Urothelial Carcinoma

Histopathology of Disseminated Mycobacterium bovis Infection Complicating Intravesical BCG Immunotherapy for Urothelial Carcinoma

Intravesical BCG Therapy as Cause of Miliary Pulmonary Tuberculosis

BCG-induced pneumonitis with lymphocytic pleurisy in the absence of elevated KL-6

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