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

Mycobacterium bovis Infections Following Intravesical Bacillus Calmette-Guérin Instillation for Bladder Cancer in Western Australia: A 22-Year Retrospective Review

Mycobacterium bovis bacillus Calmette-Guérin (BCG) infection following intravesical BCG instillation is a rare complication of therapy that is associated with significant morbidity and mortality. We conducted a multicenter retrospective review of microbiologically confirmed M.bovis BCG infections in Western Australia over 22 years. Thirty-three patients were included in our study. All patients were male with a median age of 72 years. Localized infections accounted for 22/33 cases while disseminated infections accounted for 11/33 cases. The majority (n = 21) of positive isolates were cultured from urine specimens, followed by tissue and blood. The median time between first BCG instillation and infection was 7.5 months (95% CI, 3.5-11.5). The median duration of antimycobacterial therapy for localized infections was 6 months (95% CI, 4.1-7.9) as compared with 9 months (95% CI, 7.9-10.1) for disseminated infections (P = .039). The attributed mortality was 14.3%. M.bovis BCG infections have diverse clinical presentations and clinicians must have a high index of suspicion when assessing patients with a history of intravesical BCG instillation.

Lumbosacral Vertebral Osteomyelitis With Iliopsoas and Epidural Abscess Following Intravesical Bacillus Calmette-Guérin Therapy

Intravesical Bacillus Calmette-Guérin (BCG) therapy is the gold-standard adjuvant therapy for patients with superficial or non-muscle-invasive bladder cancer. BCG is a live attenuated strain of Mycobacterium bovis, which induces an antitumor environment, effectively fighting malignant uroepithelial cells through cytotoxic reactions. However, BCG therapy may stimulate local or disseminated infections. In rare cases, vertebral osteomyelitis may arise in the thoracolumbar spine, mostly affecting older males. This is a case of an 84-year-old male patient who developed L5-S1 osteomyelitis with associated epidural and iliopsoas abscess. Symptoms manifested as severe low back pain and bilateral lower extremity weakness. This paper aims to raise awareness of and educate spine surgeons in recognizing this uncommon complication by taking into context a history of BCG therapy.

Tubercular Spondylitis: A Rare Complication of BCGosis Masquerading as Metastasis on 18F-PSMA-1007 PET/CT

ABSTRACT

BCGosis is a rare complication of intravesical BCG immunotherapy as adjuvant therapy for urinary bladder cancer manifesting in the form of disseminated tuberculosis or organ-specific tuberculosis, rarely involving the vertebra. PSMA is overexpressed in prostate cancer but also expressed in a variety of benign and malignant conditions. We present a patient with incidental detection of abnormal uptake in a vertebral lesion during assessment of prostate cancer with 18F-PSMA PET/CT, subsequently proven to be vertebral osteitis, likely due to BCG immunotherapy. The case highlights the role of interdisciplinary patient assessment to confirm nature of abnormal foci on 18F-PSMA PET/CT.

Bacillus Calmette-GuÉrin-Associated Cervical Spondylitis in a 3-Year-Old Immunocompetent Girl

Bacillus Calmette-Guérin (BCG)-associated osteomyelitis is a rare adverse event following BCG vaccination, and there have been no previous reports of BCG-associated cervical spondylitis. Here, we describe the case of a 3-year-old immunocompetent girl who developed BCG-associated cervical spondylitis and was successfully treated by prompt surgical drainage of the abscess and administration of isoniazid and rifampicin for 9 months without sequelae.

Tuberculous spondylitis following intravesical bcg-instillation in the treatment of transitional cell carcinoma: Case report and systematic review

OBJECTIVES

Tuberculous spondylitis (TS), also known as Pott's disease (PD), is a form of tuberculosis in which the vertebral column is affected. Since the first description by Katz et al. in 1992, it became clear that Bacillus Calmette-Guérin (BCG) instillations in the treatment of superficial transitional cell carcinoma (TCC) form a plausible way in which PD is introduced. Nowadays, BCG forms the most effective treatment modality for superficial TCC. The incidence of other than minor complications have been estimated under five per cent. Here we report a case of TS after BCG-instillation in the treatment of TCC. Furthermore, all available literature concerning this topic was gathered into a systematic review. The primary objective was to create an overview of all available literature concerning TS after intravesical BCG-instillations, with an emphasis on the neurosurgical approach of these patients, forming a scaffold at which future case reports can be compared. As a secondary objective, we tried to raise the awareness concerning this very rare complication of intravesical BCG-instillation as a possible cause of low back pain (LBP).

PATIENTS AND METHODS

We performed a systematic review, in which patients who developed TS after intravesical BCG-therapy in the treatment of TCC, were examined. A total of twenty-three articles (twenty-four cases) obtained from MEDLINE were included. Search terms included: "tuberculous spondylitis", "Pott's disease", "vertebral osteomyelitis", "intravesical", "Bacillus Calmette-Guérin" and "transitional cell carcinoma". Additional studies were identified by checking reference lists. Furthermore, we present a case concerning one of our own patients who consulted our Neurosurgical department with a similar clinical presentation. This systematic review is in conformity with the PRISMA-guidelines. The case report is in accordance with the CARE statement guidelines.

RESULTS

Results are based on twenty-five cases (twenty-four cases extracted from previous literature and our case report). All included articles are case reports written in English. Publication year and recruitment time varies from 1992 to 2018. Mean age at clinical presentation varies from 35 to 94 years old (mean 74). All patients were male. Surgery was performed in 17 out of 25 cases (68%). A posterior approach was performed in seven cases (41%), zero anterior approaches (0%), a combined approach in five cases (29%) and not specified in five cases (29%). All patients received intravesical BCG-instillation in the treatment of TCC, ranging from one month to twelve years before clinical presentation (mean 26). Radiographic abnormalities were seen in thoracic vertebral segments in thirteen cases (52%), eleven cases in lumbar segments (44%), one at the thoracolumbar transition level (4%) and not in cervical vertebral segments.

CONCLUSION

Although very rare, TS should be part of the differential diagnosis in patients with LBP, even years after BCG-instillation for TCC. It mostly affects elderly men and involves the thoracolumbar spine through hematogenous spread via Batson's plexus. Antitubercular therapy remains the mainstay in the treatment of TS. A posterior surgical approach, with debridement and stabilization, should be preferred when surgical intervention seems necessary. To our knowledge, this systematic review forms one of the first comprehensive reviews evaluating neurosurgical intervention for PD following intravesical BCG-therapy in the treatment of TCC.