SESSION TITLE: Infectious Disease Student/Resident Cases
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 07:30 AM - 08:30 AM
INTRODUCTION: Bacillus Calmette-Guerin (BCG) is a live attenuated bacterium derived from Mycobacterium bovis. When given intravesicularly, BCG is an effective form of immunotherapy for early-stage bladder cancer. Intravesical BCG treatment is usually well tolerated. Infrequently, systemic absorption of BCG can result in disseminated infection. We describe a case of disseminated Mycobacterium bovis infection in an immunocompetent adult after intravesical BCG immunotherapy.
CASE PRESENTATION: A 56 year old man with stage I renal cell carcinoma, stage 0 bladder carcinoma, and stage III carcinoma of the renal pelvis status post left nephroureterectomy, presented with several weeks of unremitting fever, without cough or shortness of breath. He had recently completed five cycles of BCG immunotherapy after transurethral resection of a bladder tumor. His physician prescribed isoniazid, pyridoxine, rifampin, and ethambutol for presumed BCG-osis. He presented to the hospital two months later with fever and 20 pound weight loss. Liver function tests (LFTs) were elevated: AST= 78 units/L, ALT= 59 units/L, alkaline phosphatase= 547 units/L, and total bilirubin= 1.7 mg/dl. Absolute neutrophil count was 1650 cells/mm3. Serologies for hepatitis A, B, and C, and Quantiferon Gold test were negative. Computed tomography (CT) of the abdomen showed new periportal edema with hepatic nodules, small ascites, and reactive mesenteric nodes. Chest CT showed interlobular septal thickening, with ground-glass nodules in the upper lobes as well as small bilateral pleural effusions. Bronchoalveolar lavage from bronchoscopy was negative for AFB stain and culture. Cytology showed no malignant cells. Medications were held and laboratory values improved. After discharge, he completed six months of antimycobacterial therapy. Repeat CT of the chest and abdomen five months later showed resolution of the lung and abdominal findings.
DISCUSSION: BCG-osis is an uncommon adverse effect of intravesical BCG immunotherapy. Risk factors include recent bladder tumor resection and traumatic installation, though the latter is not always noted. Systemic illness can occur at any time. Patients who present within three months of intravesical therapy are stratified to early-presentation disease, and can be immunocompetent, as was our patient. Organisms are generally susceptible to isoniazid, rifampin, and ethambutol and resistant to pyrazinamide. Response is usually favorable though LFTs should be monitored.
CONCLUSIONS: BCG immunotherapy can cause disseminated BCG-osis in immunocompetent adults treated for bladder cancer. Persistent unexplained fever following intravesical BCG should prompt a clinical suspicion for BCG-osis.
Reference #1: Gonzalez OY, Musher DM, Brar I, et al. Spectrum of Bacille Calmette-Guerin (BCG) Infection after Intravesical BCG Immunotherapy. Clinical Infectious Diseases 2003; 36:140-8.
DISCLOSURE: The following authors have nothing to disclose: Richard May, Chinenye Emuwa, Amee Patrawalla, Andrew Berman
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