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Rajabi A, Pouladfar G, Dehghan Y, Jafarpour Z, Dehghan A. Disseminated Bacillus Calmette-Guérin infection: role of imaging in the evaluation of complications. J Trop Pediatr 2023; 69:fmad024. [PMID: 37616069 DOI: 10.1093/tropej/fmad024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
BACKGROUND The Bacillus Calmette-Guerin (BCG) vaccine is generally used to prevent tuberculosis, particularly meningeal and miliary types, in childhood. This vaccine can rarely cause complications of varying severity, ranging from localized disease to a severe diffuse type known as disseminated BCG infection. Imaging modalities play an important role in the evaluation of different complications of disseminated BCG infection. This study aimed to assess and describe the imaging findings of disseminated BCG infection in order to help clinicians diagnose this life-threatening infection more accurately. METHODS This retrospective study was performed on 44 hospitalized children diagnosed with disseminated BCG infection. The results of radiographs, sonography, computerized tomography (CT) scan and magnetic resonance imaging were compiled in a checklist and were then assessed by a radiology resident and a board-certificated radiologist. The radiological findings from various imaging modalities were presented descriptively and the frequency of different parameters was reported. RESULTS Axillary lymphadenopathy at the vaccinated side was frequent and was often associated with abscesses. However, abscesses in other body regions were uncommon. The most common abdominal imaging findings were enlarged liver and spleen accompanied by multiple hypoechoic and hypodense nodules on ultrasound and CT scans, respectively. Furthermore, diffuse or multifocal pulmonary opacities were the most frequent findings on chest X-rays and CT scans. CONCLUSION Characteristic imaging findings of disseminated BCG infection play a vital role in the early diagnosis of this infection. The study findings demonstrated the importance of radiological imaging in the diagnosis and evaluation of the complications of disseminated BCG infection.
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Affiliation(s)
- Ardeshir Rajabi
- Medical Imaging Research Center, Shiraz University of Medical Sciences, Shiraz 7193635899, Iran
| | - Gholamreza Pouladfar
- Alborzi Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz 7134814336, Iran
| | - Yasamin Dehghan
- School of Medicine, Shiraz University of Medical Sciences, Shiraz 7134814336, Iran
| | - Zahra Jafarpour
- Alborzi Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz 7134814336, Iran
| | - Alireza Dehghan
- Medical Imaging Research Center, Shiraz University of Medical Sciences, Shiraz 7193635899, Iran
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Yang X, Toh Q, Huang HH, Sng LH, Tan TT, Ng LG. Intravesical Bacillus Calmette-Guerin and its complications: 12 years of learning experience in a single local institution. Singapore Med J 2022; 63:325-329. [PMID: 36043299 PMCID: PMC9329553 DOI: 10.11622/smedj.2020168] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Intravesical Bacillus Calmette-Guerin (BCG) therapy is the standard adjuvant treatment for non-muscle-invasive bladder carcinoma (NMIBC) with carcinoma in situ, in addition to tumour resection. We aimed to study BCG complications that preclude adequate treatment of NMIBC in an Asian population. METHODS This retrospective study was conducted using a large, prospectively maintained bladder cancer database. 336 patients received intravesical BCG therapy for bladder cancer in our institution between 2004 and 2016, with an average follow-up duration of 63 months. RESULTS The study included 258 (76.8%) male and 78 (23.2%) female patients. The median age of the patients at diagnosis of bladder cancer was 69 (range 17-94) years, and the median number of BCG instillations was 6 (range 1-27). 52 (15.5%) patients received maintenance therapy. The most common complications included urinary tract infection with/without sepsis (n = 18, 5.4%), haematuria (n = 9, 2.7%) and acute urinary retention (n = 4, 1.2%). 93.3% of the patients with complications presented early, within one month of completion of therapy. 22 out of 30 complications were Clavien-Dindo grade ≤ 2. 10 (33.3%) patients were admitted to hospital because of BCG-related adverse effects. The most common reasons for termination were urosepsis (2/30, 6.7%) and acute urinary retention (2/30, 6.7%). Patients aged ≥ 80 years at diagnosis were at higher risk of developing BCG-related complications (19.0% vs. 7.5%, p = 0.01). CONCLUSION This retrospective cohort and subgroup study showed that intravesical BCG therapy is well tolerated and has a low incidence of complications even in the elderly and patients with multiple comorbidities.
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Affiliation(s)
- XinYan Yang
- Department of Urology, Singapore General Hospital, Singapore
| | - Qi Toh
- Department of Urology, Singapore General Hospital, Singapore
| | - Hong Hong Huang
- Department of Urology, Singapore General Hospital, Singapore
| | - Li-Hwei Sng
- Department of Microbiology, Singapore General Hospital, Singapore
| | - Thuan Tong Tan
- Department of Infectious Diseases, Singapore General Hospital, Singapore
| | - Lay Guat Ng
- Department of Urology, Singapore General Hospital, Singapore
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Severe Respiratory Failure Due to Pulmonary BCGosis in a Patient Treated for Superficial Bladder Cancer. Diagnostics (Basel) 2022; 12:diagnostics12040922. [PMID: 35453970 PMCID: PMC9026867 DOI: 10.3390/diagnostics12040922] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/04/2022] [Accepted: 04/06/2022] [Indexed: 12/13/2022] Open
Abstract
Intra-vesical instillations with bacillus Calmette-Guerin (BCG) are the established adjuvant therapy for superficial bladder cancer. Although generally safe and well tolerated, they may cause a range of different, local, and systemic complications. We present a patient treated with BCG instillations for three years, who was admitted to our hospital due to fever, hemoptysis, pleuritic chest pain and progressive dyspnea. Chest computed tomography (CT) showed massive bilateral ground glass opacities, partly consolidated, localized in the middle and lower parts of the lungs, bronchial walls thickening, and bilateral hilar lymphadenopathy. PCR tests for SARS-CoV-2 as well as sputum, blood, and urine for general bacteriology—were negative. Initial empiric antibiotic therapy was ineffective and respiratory failure progressed. After a few weeks, a culture of M. tuberculosis complex was obtained from the patient’s specimens; the cultured strain was identified as Mycobacterium bovis BCG. Anti-tuberculous treatment with rifampin (RMP), isoniazid (INH) and ethambutol (EMB) was implemented together with systemic corticosteroids, resulting in the quick improvement of the patient’s clinical condition. Due to hepatotoxicity and finally reported resistance of the BCG strain to INH, levofloxacin was used instead of INH with good tolerance. Follow-up CT scans showed partial resolution of the pulmonary infiltrates. BCG infection in the lungs must be taken into consideration in every patient treated with intra-vesical BCG instillations and symptoms of protracted infection.
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Sanville BC, Kuhn BT. A 56-Year-Old Male With Weight Loss, Night Sweats, Dyspnea, and Bladder Cancer. J Investig Med High Impact Case Rep 2021; 9:2324709621997246. [PMID: 33645301 PMCID: PMC7917849 DOI: 10.1177/2324709621997246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
A 56-year-old man presented with subacute night sweats, fever, and weight loss with worsening dyspnea. Computed tomography (CT) scan demonstrated miliary pattern of nodules evenly distributed throughout all lung fields. Given the patient's CT findings and temporal association with Bacille Calmette-Guerin (BCG) immunotherapy for bladder cancer, the patient was diagnosed with disseminated Mycobacterium bovis secondary to BCG bladder instillations.
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Affiliation(s)
- Bradley C Sanville
- Division of Pulmonary and Critical Care Medicine, University of California Davis Medical Center, Sacramento, CA, USA
| | - Brooks T Kuhn
- Division of Pulmonary and Critical Care Medicine, University of California Davis Medical Center, Sacramento, CA, USA
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Miliary tuberculosis secondary to intravesical instillation of Bacillus Calmette-Guérin. Report of two cases. Infect Dis Now 2020; 51:213-215. [PMID: 33038446 DOI: 10.1016/j.medmal.2020.09.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 09/28/2020] [Indexed: 11/24/2022]
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Marques M, Vazquez D, Sousa S, Mesquita G, Duarte M, Ferreira R. Disseminated Bacillus Calmette-Guérin (BCG) infection with pulmonary and renal involvement: A rare complication of BCG immunotherapy. A case report and narrative review. Pulmonology 2019; 26:346-352. [PMID: 31711964 DOI: 10.1016/j.pulmoe.2019.10.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 09/30/2019] [Accepted: 10/04/2019] [Indexed: 11/29/2022] Open
Abstract
Intravesical Bacillus Calmette-Guérin (BCG) instillation is a mainstay of adjunctive therapy for superficial bladder cancer that increases length of disease progression-free survival. Although usually well tolerated, moderate to severe local and systemic infectious complications can occur with this immunotherapy. Diagnosis is difficult and often based on high clinical suspicion since in many cases Mycobacterium bovis is not isolated. Treatment is not fully standardized but the combination of anti-tuberculosis drugs and corticosteroids is advocated in severe cases. The authors present an unusual case of a severe infectious complication following intravesical BCG instillation with pulmonary and kidney involvement. Prompt anti-tuberculosis treatment associated to corticosteroid resulted in a marked clinical and radiological improvement, supporting the diagnosis of disseminated BCG infection. Based on this, the authors aimed to review the literature on this exceptional complication of this immunotherapy.
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Affiliation(s)
- Marta Marques
- Serviço de Medicina Interna, Centro Hospitalar Póvoa de Varzim/Vila do Conde, Portugal.
| | - Dolores Vazquez
- Serviço de Medicina Interna, Centro Hospitalar Póvoa de Varzim/Vila do Conde, Portugal
| | - Susana Sousa
- Serviço de Medicina Interna, Centro Hospitalar Póvoa de Varzim/Vila do Conde, Portugal
| | - Gonçalo Mesquita
- Serviço de Medicina Interna, Centro Hospitalar Póvoa de Varzim/Vila do Conde, Portugal
| | - Maria Duarte
- Serviço de Medicina Interna, Centro Hospitalar Póvoa de Varzim/Vila do Conde, Portugal
| | - Rosa Ferreira
- Serviço de Medicina Interna, Centro Hospitalar Póvoa de Varzim/Vila do Conde, Portugal
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Clinical Spectrum of Complications Induced by Intravesical Immunotherapy of Bacillus Calmette-Guérin for Bladder Cancer. JOURNAL OF ONCOLOGY 2019; 2019:6230409. [PMID: 30984262 PMCID: PMC6431507 DOI: 10.1155/2019/6230409] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 01/24/2019] [Accepted: 02/12/2019] [Indexed: 12/13/2022]
Abstract
Because of its proven efficacy, intravesical Bacillus Calmette-Guérin (BCG) immunotherapy is an important treatment for nonmuscle invasive bladder cancer at high risk of recurrence or progression. However, approximately 8% of patients have to stop BCG instillation as a result of its complications. Complications induced by BCG therapy can have a variety of clinical manifestations. These adverse reactions may occur in conjunction with BCG instillation or may not develop until months or years after BCG cessation. An essential step in the management complications arising from BCG is early establishment of diagnosis, particularly for distant, disseminated, and obscure infections. Therefore we reviewed the literature on the potential complications after intravesical BCG immunotherapy for bladder cancer and provide an overview on the incidence, diagnosis, and treatment modality of genitourinary and systemic BCG-induced complications.
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Disseminated Granulomatous Disease from Intravesical Instillation of Bacillus Calmette-Guerin. Case Rep Oncol Med 2018; 2018:8280527. [PMID: 30245898 PMCID: PMC6136544 DOI: 10.1155/2018/8280527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 08/03/2018] [Indexed: 11/19/2022] Open
Abstract
Intravesical instillation of Bacillus Calmette-Guerin is one of the standard treatment options for superficial bladder cancer. While Bacillus Calmette-Guerin therapy is usually well tolerated with most patients experiencing only cystitis, in rare cases, it can lead to disseminated granulomatous disease. We present a case of a 72-year-old man with disseminated granulomatous disease from intravesical BCG instillation whose treatment was complicated by antimycobacterial drug toxicity.
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Robinson ARL, Radhakrishnan R, Horvath R, Pandey S. A case of disseminated Mycobacterium bovis
2 years post-intravesicular Bacillus Calmette-Guérin therapy for superficial urinary bladder cancer. Intern Med J 2017; 47:820-823. [DOI: 10.1111/imj.13475] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 02/27/2017] [Accepted: 04/09/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Alexander R. L. Robinson
- School of Medicine; The University of Queensland; Brisbane Queensland Australia
- Department of Internal Medicine; The Prince Charles Hospital; Brisbane Queensland Australia
| | | | - Robert Horvath
- Department of Internal Medicine; The Prince Charles Hospital; Brisbane Queensland Australia
| | - Sushil Pandey
- Queensland Mycobacterium Reference Laboratory; Pathology Queensland; Brisbane Queensland Australia
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Case Presentation: Lung Consolidation as Sequelae of BCG Sepsis After Combined Intravesical and Intraurethral BCG. Urol Case Rep 2017; 13:152-153. [PMID: 28567334 PMCID: PMC5440684 DOI: 10.1016/j.eucr.2017.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 04/20/2017] [Indexed: 10/25/2022] Open
Abstract
BCG sepsis is rarely seen with modern intravesical therapy and therefore its presentation may not be apparent to recently trained urologists. We describe BCG sepsis occurring in a patient treated with combined intravesical and intraurethral BCG which resulted in lung consolidation with acid-fast bacilli requiring cessation of BCG and initiation of systemic antibiotic therapy.
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Fever of unknown origin (FUO) due to miliary BCG: The diagnostic importance of morning temperature spikes and highly elevated ferritin levels. Heart Lung 2017; 46:205-207. [PMID: 28258759 DOI: 10.1016/j.hrtlng.2017.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 01/19/2017] [Accepted: 01/22/2017] [Indexed: 11/23/2022]
Abstract
Fever of unknown origin (FUO) is defined as prolonged fever of >101 °F for at least 3 weeks that remains undiagnosed after a focused inpatient or outpatient workup. One of the most elusive FUO diagnoses is miliary tuberculosis (TB) which typically has few/no localizing signs/symptoms. Since the introduction of intravesicular Bacille Calmette-Guerin (BCG) treatment for bladder carcinoma, miliary BCG has only rarely been reported as a cause of FUO. As with miliary TB, there are few/no clues to suspect miliary BCG. We present an interesting case of FUO due to miliary BCG without any localizing signs, i.e., no lung, liver or prostate involvement. The only clues to the diagnosis of this FUO due to disseminated BCG were morning temperature spikes and otherwise unexplained highly elevated ferritin levels.
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Kaburaki K, Sugino K, Sekiya M, Takai Y, Shibuya K, Homma S. Miliary Tuberculosis that Developed after Intravesical Bacillus Calmette-Guerin Therapy. Intern Med 2017. [PMID: 28626185 PMCID: PMC5505915 DOI: 10.2169/internalmedicine.56.8055] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
As a treatment for superficial transitional cell carcinoma, Bacillus Calmette-Guerin (BCG) intravesical instillation can rarely cause unpredictable systemic side effects. We describe a patient admitted due to continuous pyrexia and general fatigue. He was previously treated with intravesical BCG. Laboratory data indicated a hepatic disorder, and chest computed tomography revealed extensive bilateral miliary nodules. Transbronchial lung biopsy specimens showed several small noncaseating granulomas. The diagnosis was unsolved on the basis of acid fast staining, polymerase chain reaction and microbiological cultures, so we considered the possibility of BCG side effect-induced granuloma. Two months after treatment with antituberculous agents and corticosteroids, his clinical symptoms were improved.
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Affiliation(s)
- Kyohei Kaburaki
- Department of Respiratory Medicine, Toho University School of Medicine, Japan
| | - Keishi Sugino
- Department of Respiratory Medicine, Toho University School of Medicine, Japan
| | - Muneyuki Sekiya
- Department of Respiratory Medicine, Toho University School of Medicine, Japan
| | - Yujiro Takai
- Department of Respiratory Medicine, Toho University School of Medicine, Japan
| | - Kazutoshi Shibuya
- Department of Surgical Pathology, Toho University School of Medicine, Japan
| | - Sakae Homma
- Department of Respiratory Medicine, Toho University School of Medicine, Japan
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Abstract
Surgical pathology results can play a crucial role in the management of immunocompromised patients. Here we highlight factors that differ between immunocompromised and immunocompetent hosts, such as variation in inflammatory response. Conditions that are covered include drug reactions, disease within solid organ allografts, immune reconstitution inflammatory syndrome, specific immunodeficiency syndromes, neoplasms related to viral infections, and viral, bacterial, fungal, and parasitic infections. Special techniques including immunohistochemistry, in situ hybridization and molecular detection of pathogen nucleic acid from formalin-fixed, paraffin-embedded tissue are discussed.
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Caravaca-Fontán F, Cano Megías M, Sánchez-Conde M, Elías Triviño S, Fernández-Rodríguez A, Liaño F. Subacute interstitial pneumonitis due to Mycobacterium bovis after intravesical bacillus Calmette-Guérin instillation in a renal transplant patient. Nefrologia 2016; 36:711-713. [PMID: 27445097 DOI: 10.1016/j.nefro.2016.06.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 06/13/2016] [Indexed: 11/17/2022] Open
Affiliation(s)
| | - Marta Cano Megías
- Servicio de Nefrología, Hospital Universitario Príncipe de Asturias, Alcalá de Henares (Madrid), España
| | - Matilde Sánchez-Conde
- Unidad de Enfermedades Infecciosas/VIH, Hospital General Universitario Gregorio Marañón, Madrid, España
| | | | | | - Fernando Liaño
- Servicio de Nefrología, Hospital Universitario Ramón y Cajal, Madrid, España
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Spinal tuberculosis with severe neurological symptoms as a complication of intravesical BCG therapy for carcinoma of the bladder. Neurol Neurochir Pol 2016; 50:131-8. [DOI: 10.1016/j.pjnns.2015.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 12/14/2015] [Indexed: 11/20/2022]
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Intravesical BCG therapy as cause of miliary pulmonary tuberculosis. Urologia 2015; 83:49-53. [PMID: 26616461 DOI: 10.5301/uro.5000130] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2015] [Indexed: 11/20/2022]
Abstract
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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Gerogianni I, Gravas S, Gourgoulianis K, Neonakis I, Petinaki E. Disseminated Bacillus Calmette-Guerin infections after intravesical therapy. Indian J Med Microbiol 2014; 32:438-9. [PMID: 25297033 DOI: 10.4103/0255-0857.142254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Intravesical instillation of Bacillus Calmette-Guerin (BCG) is the treatment of choice for superficial bladder carcinoma. Disseminated BCG infection presenting as granulomatous hepatitis or pneumonitis is a very rare complication of this treatment. Here we report a case series of seven patients previously treated with BCG presenting with pneumonitis. In two of the cases, identification of Mycobacterium bovis was achieved with molecular methods.
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Affiliation(s)
| | | | | | | | - E Petinaki
- Department of Microbiology, University Hospital of Larissa, Greece
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Pérez-Jacoiste Asín MA, Fernández-Ruiz M, López-Medrano F, Lumbreras C, Tejido Á, San Juan R, Arrebola-Pajares A, Lizasoain M, Prieto S, Aguado JM. Bacillus Calmette-Guérin (BCG) infection following intravesical BCG administration as adjunctive therapy for bladder cancer: incidence, risk factors, and outcome in a single-institution series and review of the literature. Medicine (Baltimore) 2014; 93:236-254. [PMID: 25398060 PMCID: PMC4602419 DOI: 10.1097/md.0000000000000119] [Citation(s) in RCA: 181] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Bacillus Calmette-Guérin (BCG) is the most effective intravesical immunotherapy for superficial bladder cancer. Although generally well tolerated, BCG-related infectious complications may occur following instillation. Much of the current knowledge about this complication comes from single case reports, with heterogeneous diagnostic and therapeutic approaches and no investigation on risk factors for its occurrence. We retrospectively analyzed 256 patients treated with intravesical BCG in our institution during a 6-year period, with a minimum follow-up of 6 months after the last instillation. We also conducted a comprehensive review and pooled analysis of additional cases reported in the literature since 1975. Eleven patients (4.3%) developed systemic BCG infection in our institution, with miliary tuberculosis as the most common form (6 cases). A 3-drug antituberculosis regimen was initiated in all but 1 patient, with a favorable outcome in 9/10 cases. There were no significant differences in the mean number of transurethral resections prior to the first instillation, the time interval between both procedures, the overall mean number of instillations, or the presence of underlying immunosuppression between patients with or without BCG infection. We included 282 patients in the pooled analysis (271 from the literature and 11 from our institution). Disseminated (34.4%), genitourinary (23.4%), and osteomuscular (19.9%) infections were the most common presentations of disease. Specimens for microbiologic diagnosis were obtained in 87.2% of cases, and the diagnostic performances for acid-fast staining, conventional culture, and polymerase chain reaction (PCR)-based assays were 25.3%, 40.9%, and 41.8%, respectively. Most patients (82.5%) received antituberculosis therapy for a median of 6.0 (interquartile range: 4.0-9.0) months. Patients with disseminated infection more commonly received antituberculosis therapy and adjuvant corticosteroids, whereas those with reactive arthritis were frequently treated only with nonsteroidal antiinflammatory drugs (p < 0.001 for all comparisons). Attributable mortality was higher for patients aged ≥65 years (7.4% vs 2.1%; p = 0.091) and those with disseminated infection (9.9% vs 3.0%; p = 0.040) and vascular involvement (16.7% vs 4.6%; p = 0.064). The scheduled BCG regimen was resumed in only 2 of 36 patients with available data (5.6%), with an uneventful outcome. In the absence of an apparent predictor of the development of disseminated BCG infection after intravesical therapy, and considering the protean variety of clinical manifestations, it is essential to keep a high index of suspicion to initiate adequate therapy promptly and to evaluate carefully the risk-benefit balance of resuming intravesical BCG immunotherapy.
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Affiliation(s)
- María Asunción Pérez-Jacoiste Asín
- Unit of Infectious Diseases (MAPJA, MFR, FLM, CL, RSJ, ML, JMA), Department of Urology (AT, AAP), and Department of Internal Medicine (SP), Hospital Universitario "12 de Octubre," Instituto de Investigación Hospital "12 de Octubre" (i+12), Madrid, Spain
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