Concurrent granulomatous hepatitis, pneumonitis and sepsis as a complication of intravesical BCG immunotherapy

Bacillus Calmette-Guérin pneumonitis after intravesical instillation: Report of two cases and a review of the literature

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.

Septic Shock After Intravesical Therapy With Bacillus Calmette-Guerin: A Case Report of a Rare Life-Threatening Complication

Intravesical therapy with Bacillus Calmette-Guerin (BCG) is the mainstay treatment for high-risk non-muscle invasive bladder cancer. The side effects are usually local and mild. Systemic dissemination of BCG is rare, typically develops soon after instillation, and may present as a severe life-threatening condition. We present a case of a 49-year-old man under chronic haemodialysis who developed septic shock after the first BCG maintenance instillation for bladder carcinoma in situ (CIS). Supportive measures and empiric broad-spectrum antibiotic therapy were promptly started after sample collection for cultures. Lastly, the recurrence of fever raised the initial suspicion of BCG dissemination. The diagnosis was confirmed by the identification of the Mycobacterium tuberculosis complex in blood samples collected and anti-tuberculosis therapy was then initiated. We would like to highlight the need for early recognition of a systemic BCG infection and the importance of starting anti-tuberculosis treatment as early as possible.

Disseminated Bacillus Calmette-Guérin (BCG) infection presenting as severe respiratory failure and septic shock

Introduction

Intravesical Bacillus Calmette-Guérin (BCG) instillation is the most effective adjuvant therapy for superficial urinary bladder carcinoma, prolonging disease-free survival. Although it is usually well tolerated, moderate to severe local or systemic infectious complications, including sepsis involving multiple organs, may occur.

Case report

We report the unusual case of a man in his mid '70s who presented with septic shock and severe acute respiratory failure requiring intubation. Lack of response to antibiotics, history of intravesical BCG instillation and consistent imaging findings led to further investigations, with bronchoalveolar lavage (BAL) fluid polymerase chain reaction (PCR) results indicating pneumonitis due to Mycobacterium bovis dissemination. Prompt anti-tuberculosis treatment combined with corticosteroids resulted in significant clinical and radiological improvement, supporting the diagnosis of disseminated BCG infection.

Conclusions

Due to its non-specific clinical presentation and the relatively low diagnostic yield of conventional microbiological tests, a high index of suspicion is required for prompt diagnosis and treatment of systemic BCG infection. PCR-based assays for mycobacterial DNA identification may represent a valuable tool facilitating timely diagnosis of this uncommon, yet potentially life-threatening infection.

Disseminated Bacillus Calmette-Guérin infection: role of imaging in the evaluation of complications

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.

An 80-Year-Old Man With Respiratory Insufficiency After Intravesical Mycobacterium bovis BCG Immunotherapy

CASE PRESENTATION

An 80-year-old man came to the ED with fever, hematuria, and overall discomfort for 1 week. His medical history included a superficial urothelial carcinoma of the bladder for which he was adjunctively treated with intravesical Mycobacterium bovis BCG (bacillus Calmette-Guérin) immunotherapy for several months. The patient was admitted to the hospital and was initially treated with cephalosporins for a suspected complicated urinary tract infection, but his symptoms did not improve. Ten days after the initial admission, the patient developed hypoxemic respiratory failure during an episode of fever and cold chills and was admitted to the ICU.

An unusual case of a tuberculous granuloma of the liver presenting thirteen years after intravesical BCG - therapy for bladder cancer

The authors present the case of a female patient with a tumor of segment VII of the liver, which was postoperatively identified as a tuberculous granuloma. The patient was admitted for elective surgery for a liver tumor, which had been diagnosed a few months before. Computed tomography and nuclear magnetic resonance were performed, based on which focal nodular hyperplasia was suspected. Thirteen years prior to admission the patient had undergone a transurethral resection of superficial bladder carcinoma, followed by adjuvant intravesical Bacillus Calmette-Guérin (BCG-therapy). Upon surgery, segment VII of the liver was resected; postoperative course was uneventful. After the identification of granuloma, the patient was referred to a phthysiatric clinic for further diagnostics and treatment. The authors have deemed this case worthy of reporting primarily due to the exceptionally long period between the completion of BCG therapy and the onset of hepatic tumor.

A solitary pulmonary nodule caused by Mycobacterium tuberculosis var. BCG after intravesical BCG treatment: a case report

Background

Intravesical instillation of bacillus Calmette–Guérin (BCG) as a treatment for superficial bladder cancer rarely causes pulmonary complications. While published cases have been pathologically characterized by multiple granulomatous lesions due to disseminated infection, no case presenting as a solitary pulmonary nodule has been reported.

Case presentation

A man in his 70 s was treated with intravesical BCG for early-stage bladder cancer. After 1 year, he complained of productive cough with a solitary pulmonary nodule at the left lower lobe of his lung being detected upon chest radiography. His sputum culture result came back positive, with conventional polymerase chain reaction (PCR) identifying Mycobacterium tuberculosis complex. However, tuberculosis antigen-specific interferon-gamma release assay came back negative. Considering a history of intravesical BCG treatment, multiplex PCR was conducted, revealing the strain to be Mycobacterium tuberculosis var. BCG. The patient was then treated with isoniazid, ethambutol, levofloxacin, and para-aminosalicylic acid following an antibiotic susceptibility test showing pyrazinamide resistance, after which the size of nodule gradually decreased.

Conclusion

This case highlights the rare albeit potential radiographic presentation of Mycobacterium tuberculosis var. BCG, showing a solitary pulmonary nodule but not multiple granulomatous lesions, after intravesical BCG treatment. Differentiating Mycobacterium tuberculosis var. BCG from Mycobacterium tuberculosis var. tuberculosis is crucial to determine whether intravesical BCG treatment could be continued for patients with bladder cancer.

Bacillus Calmette-Guérin immunotherapy for bladder cancer: a review of immunological aspects, clinical effects and BCG infections

Bacillus Calmette-Guérin (BCG) immunotherapy for bladder cancer has been used since 1976 when the first evidence of its ability to lower recurrence and progression rates was published. Today, BCG immunotherapy is the choice of care for high-grade non-muscle invasive bladder cancer (NMIBC) after transurethral resection. This article presents indications and procedure of BCG instillations, and outlines the effects on recurrence and progression of NMIBC. The BCG-induced immunity in NMIBC is not yet fully understood. Animal studies point towards BCG inducing specific tumour immunity. We describe the current knowledge of how this immunity is induced, from internalization of BCG bacilli in urothelial cells, to cytokine- and chemokine-mediated recruitment of neutrophils, monocytes, macrophages, T cells, B cells and natural killer cells. In addition, we describe the process of trained immunity, the non-specific protective effects of BCG. Recent studies also indicate that dysbiosis of the urinary microbiome may cause lower urinary tract dysfunction. Side effects of BCG bladder instillations range from common, mild and transient symptoms, such as dysuria and flu-like symptoms, to more severe and rarely occurring life-threatening complications. We review the literature and give an overview of reported incidences and management of BCG infections after intravesical instillation.

Myeloid cell TNFR1 signaling dependent liver injury and inflammation upon BCG infection

TNF plays a critical role in mononuclear cell recruitment during acute Bacillus Calmette-Guérin (BCG) infection leading to an effective immune response with granuloma formation, but may also cause tissue injury mediated by TNFR1 or TNFR2. Here we investigated the role of myeloid and T cell specific TNFR1 and R2 expression, and show that absence of TNFR1 in myeloid cells attenuated liver granuloma formation and liver injury in response to acute BCG infection, while TNFR2 expressed in myeloid cells contributed only to liver injury. TNFR1 was the main receptor controlling cytokine production by liver mononuclear cells after antigenic specific response, modified CD4/CD8 ratio and NK, NKT and regulatory T cell recruitment. Further analysis of CD11b⁺CD3⁺ phagocytic cells revealed a TCRαβ expressing subpopulation of unknown function, which increased in response to BCG infection dependent of TNFR1 expression on myeloid cells. In conclusion, TNFR1 expressed by myeloid cells plays a critical role in mononuclear cell recruitment and injury of the liver after BCG infection.

Case Presentation: Lung Consolidation as Sequelae of BCG Sepsis After Combined Intravesical and Intraurethral BCG

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.

How to optimally manage elderly bladder cancer patients?

Bladder cancer (BCa) is a disease of the elderly and as the population is aging, BCa will become an even bigger public health challenge in the future. Nowadays the correct management of BCa in the elderly remains controversial. The purpose of this article was to review the previous literature to summarize the current knowledge. Using Medline, a non-systematic review was performed including articles between January 2000 and February 2016 in order to describe the management of BCa in the elderly in all its aspects. English language original articles, reviews and editorials were selected based on their clinical relevance. In the literature, the definition of elderly is variable and based on chronological, not biological, age. BCa seems to be more aggressive in the elderly. The management of non-muscle invasive bladder cancer (NMIBC) does not strongly differ from younger patients, except for the role of adjuvant immunotherapy. In patients with muscle invasive bladder cancer (MIBC) the role of a multidisciplinary geriatric evaluation is potentially beneficial. The curative treatment in MIBC remains radical cystectomy (RC) and elderly patients should not be withheld a potentially life-saving intervention only based on chronological age. Patients unsuitable to a major surgical approach may be eligible for bladder-sparing techniques. Geriatric assessment could help identify the frail elderly and customize their perioperative care (i.e., pre and re habilitation). In conclusion the treatment of BCa in the elderly has to be patient-centered and focused on biological age and functional reserves.

Interstitial lung disease associated with human papillomavirus vaccination

Vaccinations against the human papillomavirus (HPV) have been recommended for the prevention of cervical cancer. HPV-16/18 AS04-adjuvanted vaccines (Cervarix) are said to have favourable safety profiles. Interstitial lung diseases (ILDs) can occur following exposure to a drug or a biological agent. We report a case of ILD associated with a Cervarix vaccination. A woman in her 40's, with a history of conisation, received three inoculations of Cervarix. Three months later, she presented with a cough and shortness of breath. Findings from a computed tomography of the chest and a transbronchial lung biopsy were consistent with non-specific interstitial pneumonia. Workup eliminated all other causes of the ILD, except for the vaccination. Over the 11 months of the follow-up period, her symptoms resolved without steroid therapy. The onset and spontaneous resolution of the ILD showed a chronological association with the HPV vaccination. The semi-quantitative algorithm revealed that the likelihood of an adverse drug reaction to Cervarix was “Probable”. The outcome was relatively good, but more attention should be paid to a potential risk for HPV vaccinations to cause ILDs. Wherever possible, chest radiographic examinations should be performed in order not to overlook any ILDs.