SESSION TYPE: Infectious Disease Case Report Posters I
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: We report a case of disseminated BCG resulting from intravesical administration for bladder carcinoma to demonstrate that rarely intravesical BCG may cause appreciable toxicity.
CASE PRESENTATION: A 73-year-old male undergoing BCG treatments for urothelial carcinoma developed a fever of 39.5° C after his twelfth treatment, with vomiting, night sweats, weight loss, dyspnea, and cough. On admission he was febrile, saturating 92% on room air. Physical examination demonstrated only bibasilar rales on pulmonary auscultation. Laboratory data revealed mildly elevated transaminases, with significant CRP and ESR elevation. He had no leukocytosis, leukopenia, or positive blood cultures. Chest X-Ray demonstrated bilateral interstitial opacities and noncontrast chest CT scan illustrated bilateral parenchymal nodules in a miliary pattern without mediastinal adenopathy. Transbronchial biopsy and bronchoalveolar lavage cultures were negative, including AFB. Pathology revealed well-formed, discrete epithelioid granulomas of the lung parenchyma, one with central necrosis, with negative infectious stains. Mycobacterium bovis PCR from the sample was negative.
DISCUSSION: BCG is derived from an attenuated strain of virulent Mycobacterium bovis that can cause disease in humans. Hypersensitivity pneumonitis to BCG treatments has been reported, as has disseminated BCG infection without positive culture data. Although there appears to be an overlap, the latter has been characterized by systemic symptoms including hepatic involvement, a miliary appearance on chest imaging, and granulomata on biopsy. Due to the paucity of cases, varying presentations, and difficulty in culturing Mycobacterium bovis, a standard treatment regimen has not been established. There are reports of clinical improvement with antituberculous therapy, corticosteroids, a combination of each, as well as with cessation of BCG instillation alone. However, there are also reports of fulminant sepsis and death attributed to disseminated BCG, despite above treatment regimens. Our patient was diagnosed with disseminated BCG rather than hypersensitivity pneumonitis. He was treated with cessation of BCG and standard dose isoniazid, rifampin, and ethambutol for nine months. He has clinically improved on this regimen, supporting this diagnosis, despite lag in radiographic improvement.
CONCLUSIONS: Intravesical BCG therapy for localized bladder carcinoma is effective and generally well tolerated, however significant adverse reactions, including disseminated mycobacterial infections do occur. The clinician should be aware that this phenomenon exists so as to effectively diagnose and treat these patients.
1) Gonzalez OY, Musher DM, Baker I, et al. Spectrum of bacille Calmette-Guérin (BCG) infection after intravesical BCG immunotherapy. Clin Infect Dis 2003; 36:140-8.
2) Gupta RC, Lavengood R Jr, Smith JP. Miliary tuberculosis due to intravesical bacillus Calmette-Guérin therapy. Chest 1988; 94:1296-8.
DISCLOSURE: The following authors have nothing to disclose: Deirdre Kathman, Paulo Oliveira
No Product/Research Disclosure InformationUMass Memorial Medical Center, Worcester, MA