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Spisarova M, Losse S, Jakubec P, Hartmann I, Kral M, Ehrmann J, Szkorupa M, Studentova H, Melichar B. Bacillus Calmette-Guérin pneumonitis after intravesical instillation: Report of two cases and a review of the literature. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2024; 168:181-186. [PMID: 36628562 DOI: 10.5507/bp.2022.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 12/01/2022] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE Intravesical administration of bacillus Calmette-Guérin is standard adjuvant treatment of non-muscle invasive bladder cancer. In spite of the fact that this immunotherapy is locoregional, there are still risk of some complications. METHODS We describe two cases of systemic BCG infection after intravesical administration of BCG vaccine in patients with early stage of bladder cancer. RESULTS Both patients suffered from systemic BCG infection manifesting as BCG pneumonitis. After standard therapy with antituberculotic agents, both of them fully recovered. CONCLUSION BCG infection can occur as a rare but potentially serious complication of this treatment procedure. Gravity of this side effect and its specific therapy require prompt and right diagnosis.
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Affiliation(s)
- Martina Spisarova
- Department of Oncology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Stanislav Losse
- Department of Pneumology and Tuberculosis, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Petr Jakubec
- Department of Pneumology and Tuberculosis, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Igor Hartmann
- Department of Urology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Milan Kral
- Department of Urology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Jiri Ehrmann
- Institute of Molecular and Clinical Pathology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Marek Szkorupa
- 1st Department of Surgery, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Hana Studentova
- Department of Oncology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Bohuslav Melichar
- Department of Oncology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
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Yoshioka F, Kato T, Shima Y, Hatano K, Kawashima A, Fukuhara S, Imamura R, Nonomura N. Drug-induced interstitial pneumonia after intravesical Bacillus Calmette-Guerin administration for bladder cancer with scleroderma. IJU Case Rep 2023; 6:133-136. [PMID: 36874987 PMCID: PMC9978080 DOI: 10.1002/iju5.12569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 12/12/2022] [Indexed: 01/26/2023] Open
Abstract
Introduction Intravesical Bacillus Calmette-Guerin administration is the standard therapy for high-risk nonmuscle invasive bladder cancer and is usually well tolerated. However, some patients experience severe, potentially fatal, complications including interstitial pneumonitis. Case presentation A 72-year-old female with scleroderma was diagnosed with bladder carcinoma in situ. She developed severe interstitial pneumonitis with the first administration of intravesical Bacillus Calmette-Guerin after the cessation of immunosuppressive agents. Six days after the first administration, she experienced dyspnea at rest, and computed tomography revealed scattered frosted shadows in the upper lung. The following day, she required intubation. We suspected drug-induced interstitial pneumonia and started steroid pulse therapy for 3 days, resulting in a complete response. No exacerbation of scleroderma symptoms or recurrence of cancer was observed 9 months after Bacillus Calmette-Guerin therapy. Conclusion For patients receiving intravesical Bacillus Calmette-Guerin therapy, close observation of the respiratory condition is necessary for early therapeutic intervention.
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Affiliation(s)
- Fumie Yoshioka
- Department of Urology Osaka University Graduate School of Medicine Osaka Japan
| | - Taigo Kato
- Department of Urology Osaka University Graduate School of Medicine Osaka Japan
| | - Yoshihito Shima
- Department of Respiratory Medicine and Clinical Immunology Osaka University Graduate School of Medicine Osaka Japan.,Department of Thermo-Therapeutics for Vascular Dysfunction Osaka University Graduate School of Medicine Osaka Japan
| | - Koji Hatano
- Department of Urology Osaka University Graduate School of Medicine Osaka Japan
| | - Atsunari Kawashima
- Department of Urology Osaka University Graduate School of Medicine Osaka Japan
| | - Shinichiro Fukuhara
- Department of Urology Osaka University Graduate School of Medicine Osaka Japan
| | - Ryoichi Imamura
- Department of Urology Osaka University Graduate School of Medicine Osaka Japan
| | - Norio Nonomura
- Department of Urology Osaka University Graduate School of Medicine Osaka Japan
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Messe R, Barrera C, Gondouin A, Dalphin JC. [Hot tub lung: A retrospective analysis of 14 cases]. Rev Mal Respir 2020; 38:13-21. [PMID: 33303349 DOI: 10.1016/j.rmr.2020.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 09/16/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Hot tub lung (HTL) is a hypersensitivity pneumonitis (HP) related to inhalation of non-tuberculous mycobacteria (NTM) when exposed to ejected jet droplets from a jacuzzi. The aetiological debate is not completely settled in the literature. METHOD An observational study of 14 cases of HTL, diagnosed at the University Hospital of Besançon, France, between 2004 and 2018 according to the diagnostic criteria used in the clinic. RESULTS This cohort corresponds to type I HP (inflammatory), with one case of type II HP. Decrease of lung transfer for carbon monoxide was present in 86% of examinations (n=12/14). In total, 84% of bronchoalveolar lavages showed a lymphocytic cellular pattern≥30% (n=11/13). The environmental survey enabled the identification of NTM in 93% of cases (n=13/14), mainly Mycobacterium avium. Serum precipitins directed against NTM were found in 10% of the cases (n=2/20). Three cases received corticosteroid therapy and none received antibiotics. Antigenic eviction has improved the symptomatology in all cases. CONCLUSIONS Our cohort supports the hypothesis that HTL is predominantly a type I HP. Avoidance of the agent involved (NTM) is necessary. The diagnosis is difficult because serum precipitins against NTM are not easily demonstrable. An environmental survey could facilitate the identification of the NTM. Prevention of HTL depends on education of the clinician and the patient.
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Affiliation(s)
- R Messe
- Pôle cœur-poumon, service de pneumologie, CHU de Jean-Minjoz, Besançon, France; Service de pneumologie, hôpitaux universitaires de Genève, Genève, Suisse.
| | - C Barrera
- Pôle cœur-poumon, service de pneumologie, CHU de Jean-Minjoz, Besançon, France; Laboratoire de parasitologie mycologie, CHU de Jean-Minjoz, Besançon, France
| | - A Gondouin
- Pôle cœur-poumon, service de pneumologie, CHU de Jean-Minjoz, Besançon, France
| | - J-C Dalphin
- Pôle cœur-poumon, service de pneumologie, CHU de Jean-Minjoz, Besançon, France; UMR 6249 chrono-environnement, université de Franche-Comté, Besançon, France
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4
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Shimizu G, Amano R, Nakamura I, Wada A, Kitagawa M, Toru S. Disseminated Bacillus Calmette-Guérin (BCG) infection and acute exacerbation of interstitial pneumonitis: an autopsy case report and literature review. BMC Infect Dis 2020; 20:708. [PMID: 32993546 PMCID: PMC7523392 DOI: 10.1186/s12879-020-05396-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 09/06/2020] [Indexed: 11/16/2022] Open
Abstract
Background Intravesical administration of Bacillus Calmette–Guérin (BCG) has proven useful for treatment and prevention of recurrence of superficial bladder cancer and in situ carcinoma. However, fatal side effects such as disseminated infections may occur. Early diagnosis and accurate therapy for interstitial pneumonitis (IP) are important because exacerbation of IP triggered by infections is the major cause of death. Although some fatality reports have suggested newly appeared IP after intravesical BCG treatment, to our knowledge, there are no reports which have demonstrated acute exacerbation of existing IP. Moreover, autopsy is lacking in previous reports. We report the case of a patient with fatal IP exacerbation after BCG instillation and the pathological findings of the autopsy. Case presentation A 77-year-old man with a medical history of IP was referred to our hospital because of fever and malaise. He had received an intravesical injection of BCG 1 day before the admission. His fever reduced after the use of antituberculosis drugs, so he was discharged home. He was referred to our hospital again because of a high fever 7 days after discharge. On hospitalisation, he showed high fever and systemic exanthema. Hepatosplenomegaly and myelosuppression were also observed. Biopsies revealed multiple epithelioid cell granulomas with Langhans giant cells of the liver and bone marrow. Biopsy DNA analyses of Mycobacterium bovis in the bone marrow, sputum, and blood were negative. His oxygen demand worsened drastically, and the ground-glass shadow expanded on the computed tomography scan. He was diagnosed with acute exacerbation of existing IP. We recommenced the antituberculosis drugs with steroid pulse therapy, but he died on day 35 because of respiratory failure. The autopsy revealed a diffuse appearance of multiple epithelioid cell granulomas with Langhans giant cells in multiple organs, although BCG was not evident. Conclusions We report the first case of acute exacerbation of chronic IP by BCG infection. This is also the first case of autopsy of a patient with acute exacerbation of existing IP induced by intravesical BCG treatment. Whether the trigger of acute IP exacerbation is infection or hypersensitivity to BCG is still controversial, because pathological evidence confirming BCG infection is lacking. Physicians who administer BCG against bladder cancer should be vigilant for acute exacerbation of IP.
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Affiliation(s)
- Gen Shimizu
- Department of Neurology, Nitobe Memorial Nakano General Hospital, 4-59-16 Chuo Nakano-ku, Tokyo, 164-8607, Japan
| | - Ryota Amano
- Department of Neurology, Nitobe Memorial Nakano General Hospital, 4-59-16 Chuo Nakano-ku, Tokyo, 164-8607, Japan.
| | - Itaru Nakamura
- Department of Infection Prevention and Control, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Akane Wada
- Department of Oral Pathology, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Masanobu Kitagawa
- Department of Comprehensive Pathology, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Shuta Toru
- Department of Neurology, Nitobe Memorial Nakano General Hospital, 4-59-16 Chuo Nakano-ku, Tokyo, 164-8607, Japan
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Plion M, Dalphin JC, Soumagne T. [Adenopathy and mammary carcinoma: It is sometimes in the details that one encounters hypersensitivity pneumonitis!]. Rev Mal Respir 2020; 37:752-755. [PMID: 32888731 DOI: 10.1016/j.rmr.2020.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/04/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Hypersensitivity pneumonitis (HP) is an interstitial lung disease due to an immunological reaction to exposure, by inhalation, to a large variety of antigens. The patho-physiological mechanism remains poorly understood. The diagnosis can be challenging and requires a detailed medical history taking especially when the clinical presentation is atypical or when the causal agent remains unknown. CASE REPORT We report the case of a 75-year-old woman with a history of mammary carcinoma who presented with recently identified intramammary adenopathy. Biopsy of the adenopathy revealed non-necrotising, giant cell epithelioid granuloma. A diagnosis of hot tub lung with extra-pulmonary granulomatous lymph node involvement was made based on the clinical, functional, radiological and microbiological investigations. The evolution was favorable following antigen avoidance. CONCLUSION Extrapulmonary lymph node involvement is rare in HP, suggesting a systemic inflammatory involvement.
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Affiliation(s)
- M Plion
- Service de pneumologie, oncologie thoracique et allergologie respiratoire, CHU de Besançon, 3, boulevard Fleming, 25030 Besançon cedex, France.
| | - J-C Dalphin
- Service de pneumologie, oncologie thoracique et allergologie respiratoire, CHU de Besançon, 3, boulevard Fleming, 25030 Besançon cedex, France
| | - T Soumagne
- Service de pneumologie, oncologie thoracique et allergologie respiratoire, CHU de Besançon, 3, boulevard Fleming, 25030 Besançon cedex, France
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Okano H, Asakawa H, Nose K, Tsuruga S, Tochio T, Kumazawa H, Isono Y, Tanaka H, Matsusaki S, Sase T, Saito T, Mukai K, Nishimura A, Usui M, Baba Y, Murata T. Hepatic Injury without Granulomatous Formation Associated with Intravesical Bacillus Calmette-Guérin Therapy. Intern Med 2019; 58:1429-1432. [PMID: 30626835 PMCID: PMC6548914 DOI: 10.2169/internalmedicine.2073-18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
A 74-year-old man developed hepatic injury after intravesical Bacillus Calmette-Guérin (BCG) therapy for bladder carcinoma. Although hepatitis-associated disseminated BCG was suspected, granulomatous formations were undetectable. The hepatic injury was considered to have resulted from an allergic reaction to BCG therapy because a histopathological assessment revealed enlarged portal areas with eosinophils and neutrophils. The hepatic injury was resolved by prednisolone. This case suggested that hepatic injury associated with BCG therapy might be due to an allergic mechanism unrelated to disseminated BCG disease. A liver biopsy is needed to confirm the histopathological findings of hepatic injury after BCG therapy in order to differentiate allergic hepatic injury from infectious hepatic injury.
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Affiliation(s)
- Hiroshi Okano
- Department of Gastroenterology, Suzuka General Hospital, Japan
| | - Hiroki Asakawa
- Department of Gastroenterology, Suzuka General Hospital, Japan
| | - Kenji Nose
- Department of Gastroenterology, Suzuka General Hospital, Japan
| | - Satomi Tsuruga
- Department of Gastroenterology, Suzuka General Hospital, Japan
| | - Tomomasa Tochio
- Department of Gastroenterology, Suzuka General Hospital, Japan
| | | | - Yoshiaki Isono
- Department of Gastroenterology, Suzuka General Hospital, Japan
| | - Hiroki Tanaka
- Department of Gastroenterology, Suzuka General Hospital, Japan
| | | | - Tomohiro Sase
- Department of Gastroenterology, Suzuka General Hospital, Japan
| | - Tomonori Saito
- Department of Gastroenterology, Suzuka General Hospital, Japan
| | - Katsumi Mukai
- Department of Gastroenterology, Suzuka General Hospital, Japan
| | - Akira Nishimura
- Department of Gastroenterology, Suzuka General Hospital, Japan
| | - Miki Usui
- Department of Pathology, Suzuka General Hospital, Japan
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7
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Effects and Complications of Intravesical Instillation of Bacillus Calmette-Guerin Therapy. CURRENT BLADDER DYSFUNCTION REPORTS 2019. [DOI: 10.1007/s11884-019-00506-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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8
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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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BCGites après immunothérapie pour cancer de vessie, une pathologie hétérogène: physiopathologie, description clinique, prise en charge diagnostique et thérapeutique. Rev Mal Respir 2018; 35:416-429. [DOI: 10.1016/j.rmr.2017.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 11/20/2017] [Indexed: 11/20/2022]
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10
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Moon DS, Choi WY, Yoon NR, Kim DM. Granulomatous hepatitis in a healthy adult after bacillus Calmette-Guérin injection into a plantar wart. JAAD Case Rep 2017; 3:566-569. [PMID: 29159252 PMCID: PMC5683750 DOI: 10.1016/j.jdcr.2017.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Affiliation(s)
- Do Sik Moon
- Department of Internal Medicine, College of Medicine, Chosun University, Gwangju, Republic of Korea
| | - Woo Young Choi
- Department of Plastic and Reconstructive Surgery, College of Medicine, Chosun University, Gwangju, Republic of Korea
| | - Na-Ra Yoon
- Department of Internal Medicine, College of Medicine, Chosun University, Gwangju, Republic of Korea
| | - Dong-Min Kim
- Department of Internal Medicine, College of Medicine, Chosun University, Gwangju, Republic of Korea
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11
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Rachakonda T, Kendall B, Spivak AM, Boltax J. Pleural Effusion Caused by Bacillus Calmette-Guérin Immunotherapy for Bladder Cancer. Open Forum Infect Dis 2017; 4:ofx126. [PMID: 28761898 PMCID: PMC5534218 DOI: 10.1093/ofid/ofx126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 06/15/2017] [Indexed: 11/23/2022] Open
Abstract
Intravesical bacillus Calmette Guérin (BCG) instillation has been used as immunotherapy for early stage bladder cancer for >40 years. Complications from this therapy are rare but may result in a spectrum of infectious sequelae. Here we describe the case of an elderly man who presented with a pleural effusion and subcutaneous nodule several years after treatment with BCG.
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Affiliation(s)
| | | | | | - Jonathan Boltax
- Division of Pulmonary Medicine, University of Utah Hospital & Clinics and Huntsman Cancer Hospital, Salt Lake City
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12
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Mycotic Aneurysm after Bacillus Calmette-Guérin Treatment: Case Report and Review of the Literature. Case Rep Urol 2017; 2017:4508583. [PMID: 28316859 PMCID: PMC5337836 DOI: 10.1155/2017/4508583] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 01/24/2017] [Indexed: 11/18/2022] Open
Abstract
Background. Intravesicular Bacillus Calmette-Guérin (BCG) is an effective adjunctive therapy for superficial bladder cancer that has been shown to delay recurrence and progression of disease. Serious side effects are relatively rare but are difficult to diagnosis and commonly overlooked. Case Presentation. We report the case of a patient who was found to have mycotic aortic aneurysms secondary to treatment with BCG after a prolonged course with multiple intervening hospitalizations. Conclusion. Through this report, we discuss our present understanding of BCG infection following treatment and review the literature regarding this particular rare manifestation.
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13
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Nayar N, Briscoe K. Systemic Bacillus Calmette-Guerin sepsis manifesting as hypercalcaemia and thrombocytopenia as a complication of intravesical Bacillus Calmette-Guerin therapy. Intern Med J 2016; 45:1091-2. [PMID: 26429223 DOI: 10.1111/imj.12876] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 03/12/2015] [Indexed: 11/28/2022]
Affiliation(s)
- N Nayar
- Department of Medical Oncology, North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
| | - K Briscoe
- Department of Medical Oncology, North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
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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: 169] [Impact Index Per Article: 16.9] [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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15
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Choi CHR, Lee SO, Smith G. Subclinical miliary Mycobacterium bovis following BCG immunotherapy for transitional cell carcinoma of the bladder. BMJ Case Rep 2014; 2014:bcr-2013-201202. [PMID: 24811557 DOI: 10.1136/bcr-2013-201202] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The authors present an unusual case of a 51-year-old man who developed relatively mild non-specific symptoms following intravesical BCG instillation for superficial transitional cell carcinoma of the bladder, with radiological investigations demonstrating typical features of miliary tuberculosis (TB). Transbronchial biopsy showed small foci of poorly formed granuloma suggestive of Mycobacterium infection. The patient's respiratory symptoms only became apparent 7 days after discharge having had 4 weeks of unremarkable inpatient stay where he remained clinically well. Prompt anti-TB treatment resulted in a remarkable improvement in his symptoms and radiological appearance, supporting the diagnosis of disseminated Mycobacterium bovis infection. This case highlights the importance of recognising miliary M bovis as a potential complication in patients receiving BCG immunotherapy, and that the disease course can be subclinical with delayed onset of symptoms.
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16
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[A case with hepatitis and interstitial pneumonitis caused by intravesical bacillus Calmette-Guérin (BCG) instillation]. Nihon Hinyokika Gakkai Zasshi 2012; 102:691-5. [PMID: 22191278 DOI: 10.5980/jpnjurol.102.691] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A 49-year man, with past history of right total nephroureterectomy due to urothelial carcinoma of the right renal pelvis in September 2006 and left partial ureterectomy due to contralateral ureteral recurrence in October 2007, underwent TUR-BT due to superficial high-grade recurrent bladder cancer. After TUR-Bt, he was treated with intravesical Bacillus Calmette-Guérin (BCG) instillation at weekly intervals. Just after 5th instillation, he suffered a continuous high fever up to 38 degrees C and complained of general fatigue. Chest CT showed diffuse micronodular shadows in both lungs, and serum liver enzyme was markedly elevated. All cultures from his sputum and urine were negative for mycobacterium tuberculosis. TB-PCR test and quantiferon were also negative. These findings together with no improvement of the symptoms with anti-tuberculous treatment finally made us to judge that this was due to a hypersensitivity reaction to BCG. Soon after pulse steroid therapy, body temperature was normalized and the abnormal findings of the lung and liver disappeared.
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Turhan N, Kurt M, Ozderin YO, Kurt OK. Hepatic granulomas: a clinicopathologic analysis of 86 cases. Pathol Res Pract 2011; 207:359-65. [PMID: 21531083 DOI: 10.1016/j.prp.2011.03.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Revised: 01/17/2011] [Accepted: 03/22/2011] [Indexed: 02/03/2023]
Abstract
The aim of this study was to determine the prevalence and histopathological characteristics of hepatic granulomas. All records of liver biopsies/resections evaluated in our pathology department between 2002 and 2009 were retrospectively reviewed. Specimens with hepatic granulomas were reexamined by a designated pathologist. Type and localization of granulomas, size of granulomas and epithelioid histiocytes, and the morphological findings of surrounding liver tissue were recorded in an attempt to establish a correlation with relevant clinical, laboratory and radiological findings. Out of 1420 liver biopsy/resected specimens evaluated at our institution during the study period, 86 cases of epithelioid cell granulomas (6.05%) were observed. Of the 86 cases, 23 were men and 63 were women. The most common underlying etiology was PBC in 38 patients, infections in 34, malignancies in five, sarcoidosis in four, and foreign bodies in three patients. One case (1.2%) of a drug-induced hepatic granuloma was encountered, while another case was deemed idiopathic (of unknown etiology). Contrary to common belief, granulomas were observed not only in early stage PBC but also in cases with stage 3 disease. Out of all the PBC cases with granulomas, 55.6% had stage 3 disease, and besides periductal granulomas, intraacinar granulomas were also seen. For sarcoidosis, intra- and peri-granulomatous fibrosis was observed in as many as 75% of cases. A large majority of granulomas (82.4%) associated with infections were of the necrotizing type. Extensive evaluation of the morphological characteristics of hepatic granulomas and surrounding liver tissue along with clinical, radiological, and other laboratory findings may help arrive at an accurate diagnosis in a majority of cases. Rather than being a final diagnosis, the presence of hepatic granulomas entails the need for further investigations towards identifying the underlying etiology, with a pathologist being at the center of the diagnostic process.
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Affiliation(s)
- Nesrin Turhan
- Department of Pathology, Turkiye Yuksek Ihtisas Teaching and Research Hospital, Kizilay Sk. No: 2, 06100, Sihhiye, Ankara, Turkey.
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Kaklamanos M, Hardavella G, Trigidou R, Dionellis G, Paissios N, Koulouris N, Goritsas C. Multi-organ failure with atypical liver granulomas following intravesical Bacillus Calmette-Guerin instillation. World J Hepatol 2011; 3:79-82. [PMID: 21487539 PMCID: PMC3074089 DOI: 10.4254/wjh.v3.i3.79] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Revised: 02/22/2011] [Accepted: 03/01/2011] [Indexed: 02/06/2023] Open
Abstract
Bacillus Calmette-Guerin (BCG) intravesical instillation has been adopted in the treatment of patients with superficial bladder cancer. BCG-induced disseminated infection, though rare, has been associated with the histological finding of epithelioid granulomas in different organs, including the liver. We report the case of an adult patient with multi-organ failure, who developed sepsis, acute respiratory failure and acute hepatic failure with encephalopathy whose liver biopsy confirmed the presence of atypical, granulomatous-like lesions. Recovery was observed only after empirical therapy for Mycobacterium bovis with isoniazid, rifampicin, ethambutol and steroids was introduced. This case highlights the importance of a thorough patient assessment in order to exclude other more common causes of hepatic granulomas and to confirm diagnosis. Histological findings may be non-specific when the liver is involved in BCG-induced disseminated infection.
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Affiliation(s)
- Michail Kaklamanos
- Michail Kaklamanos, Nikolaos Paissios, Constantin Goritsas, Department of Internal Medicine, "Sotiria" Hospital of Chest Diseases, Athens 11527, Greece
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Kiely B, McLaughlin AM, Lynch TH, Keane J. Intravesical bacille Calmette-Guérin-induced multiorgan failure after treatment for transitional cell carcinoma. SCANDINAVIAN JOURNAL OF UROLOGY AND NEPHROLOGY 2011; 45:278-80. [PMID: 21329482 DOI: 10.3109/00365599.2011.554858] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Intravesical bacille Calmette-Guérin (BCG) has been safely used to treat stage Ta and T1 bladder carcinoma since 1976. This report presents the case of a 56-year-old man who presented with multiorgan failure after bacille Calmette-Guérin (BCG) treatment for stage T1 transitional cell carcinoma of the bladder. On admission the patient was jaundiced, had inflammatory infiltrates on chest radiography and required dialysis for renal failure. He had a persisting fever of unknown origin and elevated cholestatic liver function tests, which prompted a liver biopsy.This demonstrated hypersensitivity hepatic granuloma but no organism was identified. He responded well to steroid and antimycobacterial treatment. A small percentage of BCG-treated patients suffer hypersensitivity side-effects (pneumonitis, hepatitis or interstitial nephritis). This complication most commonly follows a traumatic installation. Mycobacteriumbovis is rarely cultured or identified using polymerase chain reaction techniques, and the diagnosis is based on histological findings of granuloma.
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Affiliation(s)
- Bridget Kiely
- Department of Respiratory Medicine, St James’s Hospital, Dublin, Ireland.
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20
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Arend SM, van Soolingen D. Low Level INH-Resistant BCG: A Sheep in Wolf’s Clothing? Clin Infect Dis 2011; 52:89-93. [DOI: 10.1093/cid/ciq016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Affiliation(s)
- Sandra M. Arend
- Dept. of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Dick van Soolingen
- National Mycobacteria Reference Laboratory, National Institute of Public Health and the Environment (RIVM), Bilthoven, and Radboud University in Nijmegen, the Netherlands
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21
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Villamil-Cajoto I, Jove MJ, Serrano M, Pousa M. Hepapatitis granulomatosa por Mycobacterium complex secundaria a instilación intravesical con BCG. Enferm Infecc Microbiol Clin 2010; 28:759-61; author reply 761-2.. [DOI: 10.1016/j.eimc.2010.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2010] [Revised: 05/23/2010] [Accepted: 06/09/2010] [Indexed: 10/19/2022]
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22
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Imaging Appearance of Granulomatous Disease After Intravesical Bacille Calmette-Guérin (BCG) Treatment of Bladder Carcinoma. AJR Am J Roentgenol 2009; 192:1494-500. [DOI: 10.2214/ajr.08.1962] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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23
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Middelburg TA, Snels DGCTM, van Praag MCG, Rudolphus A, Arend SM, Verhard EM, Noordhoek Hegt V, de Man P. A rare complication of BCG vaccination. Int J Dermatol 2009; 48:546-8. [DOI: 10.1111/j.1365-4632.2009.03644.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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24
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Soylu A, Ince AT, Polat H, Yasar N, Ciltas A, Ozkara S, Tasci AI. Peritoneal tuberculosis and granulomatous hepatitis secondary to treatment of bladder cancer with Bacillus Calmette-Guérin. Ann Clin Microbiol Antimicrob 2009; 8:12. [PMID: 19368735 PMCID: PMC2672069 DOI: 10.1186/1476-0711-8-12] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2008] [Accepted: 04/15/2009] [Indexed: 01/12/2023] Open
Abstract
Intravesical administration of Bacillus Calmette-Guérin is used as a treatment method in superficial bladder cancer. While it is generally well tolerated, serious side effects may develop. Granulomatous hepatitis cases have been previously reported; however, only one case with tuberculous peritonitis exists in the current literature. We hereby present two cases, one of which is the second tubercular peritonitis case following Bacillus Calmette-Guérin treatment to be reported, and the other a case with granulomatous hepatitis. Complete cure was achieved in both cases with specific therapy. In the patient who developed peritonitis, intravesical Bacillus Calmette-Guérin therapy was recommenced after antituberculosis treatment, and completed without further complications.
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Affiliation(s)
- Aliye Soylu
- Department of Gastroenterology, Bakirkoy Training and Research Hospital, Istanbul, Turkey.
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25
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Mycobacterium Bovis Infection of an Axillary-Femoral Bypass Graft after Intravesical Bacille Calmette-Guérin Immunotherapy for Bladder Cancer. Am J Med Sci 2009; 337:63-4. [DOI: 10.1097/01.maj.0000308884.50320.8a] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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26
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Jose Manzanera Escribano M, Morales Ruiz E, Odriozola Grijalba M, Gutierrez Martínez E, Rodriguez Antolín A, Praga Terente M. Acute renal failure due to interstitial nephritis after intravesical instillation of BCG. Clin Exp Nephrol 2007; 11:238-240. [PMID: 17891353 DOI: 10.1007/s10157-007-0483-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2007] [Accepted: 06/08/2007] [Indexed: 11/29/2022]
Abstract
Intravesical chemotherapy with bacilli Calmette-Guerin (BCG) has been an established therapy for preventing recurrence of, and for treatment of, superficial transitional cell carcinoma of the bladder, but it is not without side effects. A variety of renal complications have been reported and attributed to mycobacterial infection. Although renal complications are uncommon, several cases of interstitial nephritis (with or without granulomas) and mesangial glomerulonephritis have been reported. We report a 76-year-old male patient who developed acute renal failure due to interstitial nephritis after intravesical instillation of BCG. Corticosteroids may serve the recovery of renal function without concomitant use of anti-tubercular therapy, provided systemic signs and mycobacterial infection are absent. Serum creatinine should be checked in at-risk patients in order to detect this complication early.
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Sood A, Sreedhar R, Kulkarni P, Nawoor AR. Hypersensitivity pneumonitis-like granulomatous lung disease with nontuberculous mycobacteria from exposure to hot water aerosols. ENVIRONMENTAL HEALTH PERSPECTIVES 2007; 115:262-6. [PMID: 17384775 PMCID: PMC1817695 DOI: 10.1289/ehp.9542] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2006] [Accepted: 11/06/2006] [Indexed: 05/14/2023]
Abstract
OBJECTIVE Human activities associated with aerosol-generating hot water sources are increasingly popular. Recently, a hypersensitivity pneumonitis (HP)-like granulomatous lung disease, with non-tuberculous mycobacteria from exposure to hot water aerosols from hot tubs/spas, showers, and indoor swimming pools, has been described in immunocompetent individuals (also called "hot tub lung"). Our objective in this study was to examine four additional cases of hot tub lung and compare these cases with others reported in the English print literature on this disease. DATA SOURCES AND EXTRACTION We retrospectively reviewed all cases (n = 4) of presumptively diagnosed hot tub lung in immunocompetent individuals at the various physician practices in Springfield, Illinois, during 2001-2005. In addition, we searched MEDLINE for cases of hot tub lung described in the literature. DATA SYNTHESIS We summarized the clinical presentation and investigations of four presumptive cases and reviewed previously reported cases of hot tub lung. CONCLUSIONS There is a debate in the literature whether hot tub lung is an HP or a direct infection of the lung by nontuberculous mycobacteria. Primary prevention of this disease relies on ventilation and good use practices. Secondary prevention of this disease requires education of both the general public and clinicians to allow for the early diagnosis of this disease.
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Affiliation(s)
- Akshay Sood
- University of New Mexico Health Sciences Center, Albuquerque, New Mexico 87131, USA.
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28
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Del Castillo Duran Y, Santos Bodí F, Castander Serentill D, Jubert Montaperto P, Espinosa Valencia P, Rabassó Sole C. [Tuberculosis miliar in a patient treated with intravesical instillations of bacillus Calmette-Guérin]. Med Intensiva 2006; 30:116-9. [PMID: 16729480 DOI: 10.1016/s0210-5691(06)74485-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Tuberculosis miliar is a very rare complication of bacillus Calmette-Guérin (BCG) immunotherapy that is associated to high mortality. Thus, early diagnosis and treatment is essential. At present, there is a polymerase chain reaction technique (PCR) which is a rapid diagnostic method with elevated sensitivity. Treatment with tuberculostatic agents should be initiated as soon as possible, the combination of corticosteroids and cycloserine in serious cases being advisable. A case of a 75 year old patient with intravesical BCG instillations after a transurethral resection of bladder cancer is presented. He was admitted to the Intensive Care Unit (ICU) due to severe acute respiratory failure evolving to acute respiratory distress syndrome (ARDS). Mycobacterium bovis DNA was identified by PCR in blood samples and bronchoaspirate (BAS). He was treated with tuberculostatic agents and corticosteroids, dying due to respiratory failure.
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Affiliation(s)
- Y Del Castillo Duran
- Unidad de Cuidados Intensivos, Hospital de Sant Pau i Santa Tecla, Tarragona, España.
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29
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Koya MP, Simon MA, Soloway MS. Complications of intravesical therapy for urothelial cancer of the bladder. J Urol 2006; 175:2004-10. [PMID: 16697786 DOI: 10.1016/s0022-5347(06)00264-3] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2005] [Indexed: 10/24/2022]
Abstract
PURPOSE Intravesical therapy is an integral part of treatment in patients with superficial urothelial carcinoma of the bladder. The American Urological Association and European Association of Urology guidelines on bladder cancer incorporate it for the treatment of superficial bladder cancer. Given the extensive use of intravesical immunotherapy and chemotherapy, it is essential for the practicing urologist to be aware of the local and systemic side effects of these therapies. MATERIALS AND METHODS We reviewed the literature on intravesical immunotherapy and chemotherapy with particular emphasis on side effects, complications and their management. A Medline search of the English language literature for the last 25 years was done on Entrez PubMed and all relevant articles were studied in full. All side effects and complications were studied and their management was reviewed. RESULTS Intravesical therapy for transitional cell carcinoma of the bladder is generally safe. There is a high incidence of local, usually self-limiting, relatively minor side effects and infrequent, potentially severe local and systemic side effects. Most side effects are avoidable. CONCLUSIONS Although intravesical therapy is generally safe, local and systemic side effects occur and it is important to be aware of them. Identifying complications early, preventing them when possible and managing them efficiently are critical. Most complications are preventable. Knowing the risks and benefits of chemotherapeutic and immunotherapeutic agents may decrease the short-term and long-term toxicity of these agents. Adherence to guidelines may prevent inappropriate use, which can lead to unnecessary complications, resulting in bladder dysfunction and even cystectomy.
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Affiliation(s)
- Madhusudan P Koya
- Department of Urology, University of Miami School of Medicine, Miami, Florida 33136, USA
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30
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Terzian C, Rahal JJ. Mycobacterial infection as a precursor to sarcoid-like, corticosteroid-responsive, diffuse granulomatous disease. Int J Infect Dis 2006; 10:407-8. [PMID: 16460980 DOI: 10.1016/j.ijid.2005.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2005] [Revised: 06/06/2005] [Accepted: 06/17/2005] [Indexed: 11/24/2022] Open
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31
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Kennedy SE, Shrikanth S, Charlesworth JA. Acute granulomatous tubulointerstitial nephritis caused by intravesical BCG. Nephrol Dial Transplant 2006; 21:1427-9. [PMID: 16455675 DOI: 10.1093/ndt/gfk071] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Sean E Kennedy
- Department of Nephrology, Prince of Wales Hospital, Barker St, Randwick, NSW 2031, Australia
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32
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Gómez-Ferrer Lozano A, Navarro Antón JA, Sala Aznar A, Mola Arizo MJ, Gonzalvo Pérez V, Cantó Faubel E, Polo i Peris AC. Neumonitis granulomatosa por instilación endovesical de BCG. Actas Urol Esp 2006; 30:839-42. [PMID: 17078584 DOI: 10.1016/s0210-4806(06)73544-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We report two cases of pulmonary BCG-induced pneumonitis recently diagnosed amongst our patients. The first case is a 81 year old man under BCG bladder instillation treatment because of high grade superficial bladder cancer who developed a severe interstitial granulomatous pneumonitis. The patient was treated with corticosteroids and tuberculostatics with a rapid and complete response. The second patient is a young man who presented only with persistent fever and also had a complete response after treatment.
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33
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Hanak V, Kalra S, Aksamit TR, Hartman TE, Tazelaar HD, Ryu JH. Hot tub lung: presenting features and clinical course of 21 patients. Respir Med 2005; 100:610-5. [PMID: 16194601 DOI: 10.1016/j.rmed.2005.08.005] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2005] [Revised: 08/17/2005] [Accepted: 08/18/2005] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hot tub lung is an emerging lung disorder associated with exposure to Mycobacterium avium complex organisms contaminating hot tub water. OBJECTIVES To define the clinical characteristics and outcome of patients with hot tub lung. METHODS Retrospective review of 21 patients diagnosed with hot tub lung at a tertiary medical center over a 7-year period. RESULTS The mean (+/-sd) age at presentation was 46 (+/- 15) years; 9 patients were men (43%). All patients described ongoing exposure to hot tubs. The most common referral diagnoses were sarcoidosis, bronchitis, and asthma. Dyspnea and cough were present in all patients, hypoxemia was noted in 10 patients (48%). High-resolution computed tomography of the chest had been performed in 20 patients and demonstrated diffuse centrilobular nodules and/or ground-glass opacities in all patients. M. avium complex was isolated from the hot tub water, respiratory secretions and/or lung tissue in all patients. Bronchoscopic or surgical lung biopsy was obtained in 18 patients and demonstrated bronchiolocentric granulomatous inflammation. With avoidance of exposure, clinical and radiologic improvement was observed in all patients. Additionally, 13 patients (62%) received corticosteroid therapy, 1 (5%) antimycobacterial therapy, 2 (10%) received both, and 5 patients (24%) received no pharmacologic therapy. CONCLUSIONS Hot tub lung likely represents hypersensitivity pneumonitis due to inhalational exposure to M. avium complex. Antimycobacterial therapy does not appear to be required in the management of this disease. Although corticosteroids may be helpful in the treatment of severely affected patients, others can be managed by avoidance of additional exposure alone.
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Affiliation(s)
- Viktor Hanak
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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34
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Marras TK, Wallace RJ, Koth LL, Stulbarg MS, Cowl CT, Daley CL. Hypersensitivity Pneumonitis Reaction to Mycobacterium avium in Household Water. Chest 2005; 127:664-71. [PMID: 15706013 DOI: 10.1378/chest.127.2.664] [Citation(s) in RCA: 123] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Hypersensitivity pneumonitis has been described with exposure to aerosolized Mycobacterium avium complex (MAC) in indoor hot tubs (hot tub lung). OBJECTIVES To describe a case of MAC-associated hypersensitivity pneumonitis-like reaction possibly from showering and review previous hot tub lung reports. METHODS For the case report, we investigated a patient with histologically diagnosed hypersensitivity pneumonitis and MAC-positive sputum culture findings. Mycobacterial cultures were obtained from his home and workplace. Isolates were typed using pulsed-field gel electrophoresis. For the review, MEDLINE and EMBASE were searched for hot tub lung reports, which were reviewed and summarized. RESULTS A 50-year-old man had progressive dyspnea and episodic fever and myalgias. Pulmonary function testing results revealed obstruction and impaired diffusion; a chest CT scan found diffuse, centrilobular, ground-glass nodules, and air trapping, and a lymphocytic alveolitis with an elevated CD4/CD8 ratio. Transbronchial biopsy showed multiple well-formed nonnecrotizing granulomas. Multiple respiratory samples and shower and bathtub specimens grew MAC, with matching pulsed-field gel electrophoresis patterns. The patient changed from showering to tub bathing. Prednisone and antimycobacterial drugs were administered for approximately 1 year. His symptoms, pulmonary function abnormalities, and CT scan findings resolved. The literature review yielded 36 cases of hot tub lung. Clinical features included dyspnea (97%), cough (78%), and fever (58%). Pulmonary function testing showed obstruction (67%), restriction (55%), and impaired diffusion (75%). A chest CT scan showed ground-glass opacification (95%) and nodules (67%). Granulomas were well-formed in 95%. Treatments included discontinuation of hot tub use and prednisone, antimycobacterial drugs, or both. Outcomes were favorable. CONCLUSIONS A hypersensitivity pneumonitis-like reaction to mycobacteria can occur from exposures other than hot tubs. There are key differences between classic hypersensitivity pneumonitis and MAC-associated hypersensitivity pneumonitis. Antimycobacterial therapy may be required. The possibility of MAC hypersensitivity pneumonitis from showering raises potential implications in the investigation of patients with hypersensitivity pneumonitis.
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Affiliation(s)
- Theodore K Marras
- Division of Respirology, Toronto Western Hospital, Edith Cavell 4-022, 399 Bathurst St, Toronto, ON, Canada M5T 2S8.
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35
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Van Outryve SM, Francque SM, Gentens PA, De Pauw FF, Van den Bogaert E, Van Marck EA, Pelckmans PA, Michielsen PP. Bacillus Calmette-Guérin-induced granulomatous hepatitis in a patient with a superficial bladder carcinoma. Eur J Gastroenterol Hepatol 2004; 16:1027-32. [PMID: 15371927 DOI: 10.1097/00042737-200410000-00012] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
A 71-year-old male patient with a superficial transitional cell carcinoma of the urinary bladder developed high fever and jaundice, accompanied by progressively increasing serum aminotransferase activities, 2 weeks after the fourth local instillation with an attenuated live strain of Mycobacterium bovis [bacillus Calmette-Guérin (BCG)]. A liver biopsy showed non-caseating granulomatous hepatitis. Cultures for mycobacteria were negative. Mycobacterial DNA was not detected in liver tissue using the polymerase chain reaction. Empirical treatment with rifampicin and isoniazid was started, resulting in partial recovery. After 6 months of therapy, however, serum aminotransferase activities were still twice the upper limit of normal. A second liver biopsy still demonstrated several granulomas. Only after addition of prednisolone, liver tests completely normalized. Also histologically the lesions improved dramatically. This suggests that the BCG hepatitis was at least partially caused by a hypersensitivity reaction. Our patient is the first reported case of BCG hepatitis with histological follow-up under therapy.
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Affiliation(s)
- Steven M Van Outryve
- Department of Gastroenterology and Hepatology, University Hospital of Antwerp, University of Antwerp, Belgium
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36
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Diner EK, Verghese M. Interstitial pneumonitis secondary to intravesical bacillus calmette-guerin for carcinoma in-situ of the bladder. Int Braz J Urol 2004; 30:400-2. [PMID: 15610574 DOI: 10.1590/s1677-55382004000500008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2004] [Accepted: 06/20/2004] [Indexed: 11/22/2022] Open
Abstract
We report an 81-year-old male who developed severe interstitial pneumonitis on maintenance intravesical Bacillus Calmette-Guerin (BCG) for in-situ carcinoma of the bladder. The patient was treated with steroids and anti-tuberculin therapy with complete response. While there is no established standard of care for the treatment of interstitial pneumonitis, recent reports describe success with combination of corticosteroids and anti-tuberculin medications. We elected to follow this precedent and treated our patient with corticosteroids and antituberculin therapy with good outcome.
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Affiliation(s)
- Eric K Diner
- Department of Urology, Washington Hospital Center, Washington, DC 20016, USA.
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37
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Orikasa K, Namima T, Ota S, Miura M, Hama H, Kimura N, Ohnuma T. Acute eosinophilic pneumonia associated with intravesical bacillus Calmette-Guérin therapy of carcinoma in situ of the bladder. Int J Urol 2004; 10:622-4. [PMID: 14633091 DOI: 10.1046/j.1442-2042.2003.00704.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A 71-year-old man with a history of rheumatoid arthritis was treated with intravesical bacillus Calmette-Guérin (BCG) instillation of 80 mg once-a-week for carcinoma in situ. He developed low-grade fever followed by dyspnea and severe hypoxemia. Radiological and laboratory studies revealed bilateral diffuse reticulonodular infiltrates and hypereosinophilia. A lymphocyte stimulation test for BCG was strongly positive. From these findings, a pulmonary hypersensitivity reaction to immunotherapy was suspected, and therefore, methylprednisolone (500 mg per day) was started. After that, the fever and dyspnea disappeared, the hypereosinophilia was normalised and chest radiography results were clear. The present case is the first reported case of eosinophilic pneumonia following intravesical BCG therapy.
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Affiliation(s)
- Kazuhiko Orikasa
- Departments of Urology, Tohoku Rosai Hospital, Dainohara, Sendai, Japan.
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38
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Gonzalez OY, Musher DM, Brar I, Furgeson S, Boktour MR, Septimus EJ, Hamill RJ, Graviss EA. Spectrum of bacille Calmette-Guérin (BCG) infection after intravesical BCG immunotherapy. Clin Infect Dis 2003; 36:140-8. [PMID: 12522745 DOI: 10.1086/344908] [Citation(s) in RCA: 130] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2002] [Accepted: 09/12/2002] [Indexed: 12/17/2022] Open
Abstract
Intravesical instillation of bacille Calmette-Guérin (BCG) effectively treats transitional cell carcinoma of the bladder. Occasionally, BCG infection complicates such treatment. In some patients, infection appears early (within 3 months after instillation) and is characterized by generalized symptoms, with pneumonitis and hepatitis. Late-presentation disease occurs >1 year after the first BCG treatment and usually involves focal infection of the genitourinary tract (the site at which bacteria were introduced) and/or other sites that are typical for reactivation of mycobacterial disease, such as the vertebral spine or the retroperitoneal tissues. Noncaseating granulomas are found in the majority of cases, whether early or late. Most patients respond to treatment with antituberculous drugs; in early-presentation disease, when features of hypersensitivity predominate, glucocorticosteroids are sometimes added. Late localized infection often requires surgical resection.
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Affiliation(s)
- Omar Y Gonzalez
- Department of Medicine, Infectious Disease Section, Baylor College of Medicine, Houston, TX 77030-3498, USA
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Rickman OB, Ryu JH, Fidler ME, Kalra S. Hypersensitivity pneumonitis associated with Mycobacterium avium complex and hot tub use. Mayo Clin Proc 2002; 77:1233-7. [PMID: 12440560 DOI: 10.4065/77.11.1233] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Many diseases, mainly infectious and inhalational, have been associated with the use of hot tubs. "Hot tub lung" is a recently described disease entity associated with Mycobacterium avium complex (MAC) and is thought to be either an infection or a hypersensitivity pneumonitis. We describe 2 patients with progressively worsening respiratory symptoms and pulmonary function, along with diffuse radiographic changes consisting primarily of ground-glass opacities. Treatment with corticosteroids, based on lung biopsies suggesting sarcoidosis in 1 patient and eosinophilic bronchiolitis in the other, resulted in little improvement with both patients experiencing respiratory failure. Both patients continued regular and continued hot tub use despite ongoing respiratory difficulties, and MAC was identified in the hot tub water and/or lung tissue from each patient. Discontinuation of hot tub use, without antimycobacterial therapy, led to prompt improvement in symptoms, pulmonary function, and radiographic abnormalities, strongly supporting a diagnosis of hypersensitivity pneumonitis. Hypersensitivity to MAC, rather than an infection, is the likely underlying mechanism in these 2 cases of hot tub lung.
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Affiliation(s)
- Otis B Rickman
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minn 55905, USA.
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Durek C, Jurczok A, Werner H, Jocham D, Bohle A. Optimal treatment of systemic bacillus Calmette-Guérin infection: investigations in an animal model. J Urol 2002; 168:826-31. [PMID: 12131375 DOI: 10.1016/s0022-5347(05)64751-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE Hematogenous spread of bacillus Calmette-Guerin (BCG) after intravesical instillation for bladder cancer is rare but it may result in systemic infection and hypersensitivity reaction. We investigated fluoroquinolones and steroids in an animal model to improve the therapeutic options in local and systemic BCG infection. Furthermore, the antitumor effectiveness of intravesical BCG with simultaneous application of fluoroquinolones and/or steroids was tested. MATERIALS AND METHODS Oral antimicrobial therapy with and without steroids was started immediately after intraperitoneal injection using fluoroquinolones or trimethoprim-sulfamethoxazole. To evaluate the therapeutic options against a hyperergic reaction after repeat systemic BCG infection re-challenge was performed with intraperitoneal BCG 7 days after primary infection and oral therapy was given with fluoroquinolones or trimethoprim-sulfamethoxazole with and without steroids. The influence of continuous oral fluoroquinolone therapy on the antitumor effect of BCG was also tested in the MB 49 orthotopic murine bladder tumor model. RESULTS After primary systemic infection fluoroquinolone therapy alone led to significantly prolonged survival in mice (log rank test p = 0.041), whereas trimethoprim-sulfamethoxazole was ineffective. There was no additional effect of steroid administration. Steroids alone led to premature death (log rank test p = 0.022). After secondary BCG infection only steroid treated animals had prolonged survival (log rank test p = 0.032), whereas antimicrobials alone had no effect. The therapeutic efficacy of BCG in the orthotopic bladder tumor model was not affected by continuous oral fluoroquinolones in terms of survival (log rank test p = 0.001) or bladder weight (Wilcoxon test p = 0.001) compared with untreated controls. CONCLUSIONS In a mouse model fluoroquinolones had a beneficial effect for primary systemic BCG infections, whereas the hyperergic reaction after repeat BCG infection was susceptible only to steroids. Administering fluoroquinolones during an intravesical treatment course does not affect the antitumor efficacy of BCG.
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Affiliation(s)
- C Durek
- Department of Urology, Medical University of Lübeck, Lübeck, Germany
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Schattner A, Gilad A, Cohen J. Systemic granulomatosis and hypercalcaemia following intravesical bacillus Calmette-Guérin immunotherapy. J Intern Med 2002; 251:272-7. [PMID: 11886488 DOI: 10.1046/j.1365-2796.2002.00957.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Ami Schattner
- Department of Medicine, Kaplan Medical Center, Rehovot, Israel.
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43
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Une septicémie à Mycobacterium bovis «souche BCG»: faut-il utiliser les corticoïdes en association avec les antituberculeux ? Med Mal Infect 2001. [DOI: 10.1016/s0399-077x(01)00161-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Elkabani M, Greene JN, Vincent AL, VanHook S, Sandin RL. Disseminated Mycobacterium bovis after intravesicular bacillus calmette-Gu rin treatments for bladder cancer. Cancer Control 2000; 7:476-81. [PMID: 11000618 DOI: 10.1177/107327480000700512] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- M Elkabani
- Department of Medicine, Division of Infectious and Tropical Diseases University of South Florida College of Medicine, Tampa, USA
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Ozbakkaloglu B, Tünger O, Sürücüoglu S, Lekili M, Kandiloglu AR. Granulomatous hepatitis following intravesical bacillus Calmette-Guerin therapy. Int Urol Nephrol 1999; 31:49-53. [PMID: 10408303 DOI: 10.1023/a:1007119706336] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Although intravesical bacillus Calmette-Guerin (BCG) administration is an effective method in the treatment of superficial urinary bladder carcinoma, some complications may arise such as a granulomatous reaction either in the urinary tract or, in rare cases, outside the urinary tract. We report in this paper a case of granulomatous hepatitis following intravesical BCG administration.
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Affiliation(s)
- B Ozbakkaloglu
- Department of Infectious Disease, Celal Bayar University, School of Medicine, Manisa, Turkey
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Abstract
We report a 58-year-old man who developed respiratory distress and interstitial shadowing on chest X-ray 10 days after receiving the influenza vaccine. He failed to respond to intravenous antibiotics but his clinical condition, hypoxia and chest X-ray changes improved dramatically on oral steroids. The clinical diagnosis was pneumonitis secondary to recent influenza vaccination.
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Paterson DL, Patel A. Bacillus Calmette-Guerin (BCG) immunotherapy for bladder cancer: review of complications and their treatment. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1998; 68:340-4. [PMID: 9631906 DOI: 10.1111/j.1445-2197.1998.tb04768.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Intravesical bacillus Calmette-Guerin (BCG) is widely used in the management of bladder cancer but because it is a living organism, local and disseminated infection may result. METHODS A prospective assessment of complications of this therapy in 200 patients in Queensland was performed. A review of management of complications of intravesical BCG was also carried out. RESULTS Major side effects were rare. Cystitis was the most common side effect, being seen to some degree in all patients, although only forcing cessation of BCG therapy in two patients. Two patients developed persistent cystitis necessitating institution of isoniazid and rifampicin. Two patients had culture-proven bladder infection that presented several months after the BCG treatment. These patients also responded to two-drug antituberculous therapy. While low-grade fever is very common with this therapy, seven patients (3.5%) had fevers of > 39 degrees C within 48 h of receiving BCG. Fevers may be an indication of severe disseminated mycobacterial infection, which has a high mortality, so it needs to be treated aggressively. Alternatively bacterial sepsis with gram-negative bacterial pathogens or a hypersensitivity reaction to BCG may cause this degree of fever, and cannot be rapidly distinguished from fulminant mycobacterial infection. One patient in the present series developed pneumonia attributed to mycobacterial dissemination. CONCLUSIONS The key to appropriate management of complications of BCG therapy is awareness of their possibility, even months or years after the therapy has been given. Appropriate empirical therapy in acute situations and mycobacterial culture in chronic situations can then be performed.
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Affiliation(s)
- D L Paterson
- Queensland Tuberculosis Control Centre, Brisbane, Australia
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Dederke B, Riecken EO, Weinke T. A case of BCG sepsis with bone marrow and liver involvement after intravesical BCG instillation. Infection 1998; 26:54-7. [PMID: 9505183 DOI: 10.1007/bf02768758] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The case described concerns a 68-year-old male patient, who received intravesical BCG instillations for non-resectable urothelial carcinoma (stage pT1, G2). After the third instillation, which was complicated by hematuria during catheterization, he had a high temperature, dyspnoea, a weight-loss of 15 kg and critical recurrent hypotension for 3 weeks. On admission to the clinic he presented with high serum liver enzymes and pancytopenia. The suspected diagnosis of BCG sepsis was confirmed by the detection of typical granulomas in liver and bone marrow histology. After initiation of tuberculostatic therapy, the patient's condition improved and laboratory results returned to normal. This case shows the potential of a life-threatening systemic side effect after intravesical BCG instillation.
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Affiliation(s)
- B Dederke
- Abt. für Innere Medizin-Gastroenterologie, Universitätsklinikum Benjamin Franklin, Berlin, Germany
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Leebeek FW, Ouwendijk RJ, Kolk AH, Dees A, Meek JC, Nienhuis JE, Dingemans-Dumas AM. Granulomatous hepatitis caused by Bacillus Calmette-Guerin (BCG) infection after BCG bladder instillation. Gut 1996; 38:616-8. [PMID: 8707098 PMCID: PMC1383125 DOI: 10.1136/gut.38.4.616] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Bladder instillations with Bacillus Calmette-Guerin (BCG) are commonly used as immunotherapy for bladder carcinoma. Sometimes patients experience serious systemic side effects, such as sepsis or pneumonitis. Granulomatous hepatitis is a rare serious side effect, which has been considered a hypersensitivity reaction to BCG. PATIENT The first case of granulomatous hepatitis after BCG bladder instillation in which mycobacteria were identified by staining techniques and mycobacterial DNA was detected in liver tissue using the polymerase chain reaction is reported. CONCLUSION The granulomatous hepatitis was caused by BCG infection of the liver after haematogenous dissemination of BCG, rather than hypersensitivity.
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Affiliation(s)
- F W Leebeek
- Department of Internal Medicine, Ikazia Hospital Rotterdam, the Netherlands
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LeMense GP, Strange C. Granulomatous pneumonitis following intravesical BCG. What therapy is needed? Chest 1994; 106:1624-6. [PMID: 7956439 DOI: 10.1378/chest.106.5.1624] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
A 68-year-old man developed fever, cough, and dyspnea after intravesical bacillus Calmette-Guerin (BCG). Chest radiograph revealed diffuse reticulonodular infiltrates with caseating granulomas on transbronchial biopsy specimen. Cultures were negative and the patient's condition improved with corticosteroids. The mechanism for BCG-induced granulomatous inflammation is poorly understood. Optimal therapy includes corticosteroids.
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Affiliation(s)
- G P LeMense
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston
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