Systemic infection following intravesical therapy with BCG

Systemic Bacillus Calmette-Guérin (BCG) Infection in a Patient With Non-Muscle-Invasive Bladder Cancer: A Case Report

Intravesical Bacillus Calmette-Guérin (BCG) instillation is a widely used adjuvant therapy for non-muscle-invasive bladder cancer (NMIBC), typically associated with a favorable safety profile. However, severe complications such as systemic BCG infection, though rare, can occur and are potentially life-threatening. Diagnosing systemic BCG infection is challenging due to frequently negative microbiological results. We report the case of a 67-year-old immunocompetent man who developed a systemic BCG infection after undergoing BCG therapy for NMIBC. Initially misdiagnosed as a urinary tract infection, his condition worsened despite antibiotic treatment. The diagnosis of BCG sepsis was suspected after prolonged fever, asthenia, and other systemic symptoms. Prompt initiation of antituberculosis treatment with rifampicin, ethambutol, and isoniazid led to a full recovery. This case underscores the critical importance of early recognition and treatment of systemic BCG infections, particularly in patients presenting with persistent fever and no clear source of infection.

BCG and Alternative Therapies to BCG Therapy for Non-Muscle-Invasive Bladder Cancer

Bladder cancer is a heterogeneous disease. Treatment decisions are mostly decided based on disease stage (non-muscle invasive or muscle invasive). Patients with muscle-invasive disease will be offered a radical treatment combined with systemic therapy, while in those with non-muscle-invasive disease, an attempt to resect the tumor endoscopically will usually be followed by different intravesical instillations. The goal of intravesical therapy is to decrease the recurrence and/or progression of the tumor. In the current landscape of bladder cancer treatment, BCG is given intravesically to induce an inflammatory response and recruit immune cells to attack the malignant cells and induce immune memory. While the response to BCG treatment has changed the course of bladder cancer management and spared many "bladders", some patients may develop BCG-unresponsive disease, leaving radical surgery as the best choice of curative treatment. As a result, a lot of effort has been put into identifying novel therapies like systemic pembrolizumab and Nadofaragene-Firadenovac to continue sparing bladders if BCG is ineffective. Moreover, recent logistic issues with BCG production caused a worldwide BCG shortage, re-sparking interest in alternative BCG treatments including mitomycin C, sequential gemcitabine with docetaxel, and others. This review encompasses both the historic and current role of BCG in the treatment of non-muscle-invasive bladder cancer, revisiting BCG alternative therapies and reviewing the novel therapeutics that were approved for the BCG-unresponsive stage or are under active investigation.

Systemic Bacillus Calmette-Guérin (BCG) Infection With Renal Involvement: A Rare Complication of BCG Immunotherapy

Intravesical instillation of bacillus Calmette-Guérin (BCG) is the adjuvant therapy for superficial urothelial carcinoma of the bladder with the lowest recurrence rates and is well tolerated with minor and self-limiting adverse effects. Serious complications, such as systemic BCG infection, are uncommon as the diagnosis is difficult and, in the majority of cases, Mycobacterium bovis cannot be isolated. We describe a case of a man who presented with prolonged fever associated with polyuria, dysuria, anorexia, and significant weight loss, refractory to several courses of appropriate antibiotic therapy. After an exhaustive investigation, the underlying diagnosis of systemic BCG infection with renal involvement was considered. Antituberculosis treatment resulted in a marked clinical and radiological recovery, supporting this diagnosis.