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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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Geetha SD, Chavarria HD, Abdelwahed M, Kataria N, Bijol V, Das K. Granulomatous myocarditis arising from intravesical Bacillus Calmette-Guérin therapy leading to death diagnosed by postmortem examination: a case report. J Med Case Rep 2024; 18:12. [PMID: 38195538 PMCID: PMC10777644 DOI: 10.1186/s13256-023-04310-4] [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: 05/02/2023] [Accepted: 12/06/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Intravesical Bacillus Calmette-Guérin (BCG) is used as a standard adjuvant therapy for non-muscle invasive urothelial cancer. Most patients tolerate the treatment well, with mild side effects. Systemic complications are extremely rare, occur due to BCG dissemination and are associated with immunocompromised state and urothelial breach. CASE PRESENTATION We present a case of a 78-year-old male, a former smoker, with history of non-muscle invasive urothelial carcinoma status post partial resection followed by intravesical BCG therapy. An autopsy was performed due to the sudden nature of his death. Autopsy showed multiple necrotizing granulomas in the brain, atrium, ventricles, lungs, kidneys, and urinary bladder. Stains for acid-fast bacilli and fungi were negative. In addition, bilateral lungs showed evidence of bronchopneumonia secondary to cytomegalovirus. CONCLUSION Granulomatous myocarditis arising from BCG therapy is extremely rare. Our patient with urothelial cancer treated with BCG developed multiorgan granulomas, most likely due to a hypersensitivity reaction to intravesical BCG. Arrhythmia induced by granulomatous myocarditis was the cause of his death. Although there have been few cases of systemic BCG-osis causing fatal sepsis leading to death, a cardiac cause of death is unique.
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Affiliation(s)
- Saroja D Geetha
- Northwell Health, Department of Pathology, Zucker School of Medicine, North Shore University Hospital/Long Island Jewish Medical Center, 2200 Northern Blvd, Suite 104, Greenvale, NY, 11548, USA.
| | - Hector D Chavarria
- Northwell Health, Department of Pathology, Zucker School of Medicine, North Shore University Hospital/Long Island Jewish Medical Center, 2200 Northern Blvd, Suite 104, Greenvale, NY, 11548, USA
| | - Mohammed Abdelwahed
- Northwell Health, Department of Pathology, Zucker School of Medicine, North Shore University Hospital/Long Island Jewish Medical Center, 2200 Northern Blvd, Suite 104, Greenvale, NY, 11548, USA
| | - Nidhi Kataria
- Northwell Health, Department of Pathology, Zucker School of Medicine, North Shore University Hospital/Long Island Jewish Medical Center, 2200 Northern Blvd, Suite 104, Greenvale, NY, 11548, USA
| | - Vanesa Bijol
- Northwell Health, Department of Pathology, Zucker School of Medicine, North Shore University Hospital/Long Island Jewish Medical Center, 2200 Northern Blvd, Suite 104, Greenvale, NY, 11548, USA
| | - Kasturi Das
- Northwell Health, Department of Pathology, Zucker School of Medicine, North Shore University Hospital/Long Island Jewish Medical Center, 2200 Northern Blvd, Suite 104, Greenvale, NY, 11548, USA
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Muacevic A, Adler JR, Pinto P, Romano M, Esteves A. Systemic Bacillus Calmette-Guérin (BCG) Infection With Renal Involvement: A Rare Complication of BCG Immunotherapy. Cureus 2022; 14:e33134. [PMID: 36726926 PMCID: PMC9886377 DOI: 10.7759/cureus.33134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2022] [Indexed: 12/31/2022] Open
Abstract
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.
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4
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Vilares AT, Nunes Silva C, Correia da Silva M, Sousa J, Viamonte B, Madureira AJ. Multisystemic BCGitis: A rare complication of intravesical BCG immunotherapy for bladder cancer. Radiol Case Rep 2022; 17:2383-2387. [PMID: 35570860 PMCID: PMC9096469 DOI: 10.1016/j.radcr.2022.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 04/11/2022] [Indexed: 11/12/2022] Open
Abstract
Intermediate- to high-grade non-muscle invasive bladder cancer is preferably treated with transurethral resection followed by adjuvant intravesical immunotherapy with Bacillus Calmette-Guérin (BCG). BCG acts as an immune stimulator, inducing a complex inflammatory response that selectively targets tumoral cells. Mild side effects of BCG instillation, such as fever, malaise, and bladder irritation are frequent, while severe treatment-associated complications of the genito-urinary tract are rare. “Distant” complications are even rarer and, since BCG is able to disseminate hematogenously, virtually all organs and systems can be involved, with the lungs, liver and musculoskeletal system being most commonly affected. Vascular complications of BCG immunotherapy are exceedingly rare and difficult to diagnose, because they can mimic other vascular infections and may occur several years after treatment. Knowledge of previous BCG immunotherapy and awareness about treatment-related complications is essential to avoid misdiagnosis, and to guide appropriate treatment.
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5
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Notghi AAA, Hosseini F, Tsogas N. Severe diffuse proliferative bronchiolitis complicating culture-proven disseminated BCG infection after intravesical instillation for bladder cancer. BMJ Case Rep 2022; 15:e248681. [PMID: 35321917 PMCID: PMC8943779 DOI: 10.1136/bcr-2021-248681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2022] [Indexed: 11/04/2022] Open
Abstract
A man in his 70s was admitted to hospital following several months of dyspnoea, night sweats, weight loss and, latterly, fevers. His symptoms correlated with a second maintenance cycle of intravesical BCG instillation for superficial bladder cancer. Blood tests showed raised C-reactive protein, alkaline phosphatase and gamma-GT, although extensive further investigations did not reveal any specific cause. Treatment for a presumed diagnosis of disseminated BCG infection was started, following which his fevers ceased. Later available results of liver biopsy taken prior to treatment supported this diagnosis, and mycobacterial blood and urine cultures grew Mycobacterium bovis Recovery was complicated by a severe diffuse proliferative bronchiolitis which responded to corticosteroids. This case highlights an important dichotomy in the pathophysiology of disseminated BCG infection. It demonstrates how morbidity can be caused by both a direct dissemination of the organism and an immune hypersensitivity response in the same patient.
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6
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Oliveira AA, Morais J, Ribeiro J, Gouveia PF. Systemic infection following intravesical therapy with BCG. BMJ Case Rep 2021; 14:e243641. [PMID: 34753717 PMCID: PMC8578936 DOI: 10.1136/bcr-2021-243641] [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] [Accepted: 10/19/2021] [Indexed: 11/03/2022] Open
Abstract
Immunotherapy with BCG is an effective and widely used treatment for non-muscle-invasive bladder cancer. BCG sepsis is a rare but life-threatening and frequently not a straightforward complication of this treatment; in cases with a high index of suspicion, anti-bacillary treatment should not wait for laboratory confirmation and be instituted immediately. We report a severe case of BCG sepsis, in which timely diagnosis and initiation of antituberculosis agents enabled a full recovery.
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Affiliation(s)
| | - Joana Morais
- Department of Internal Medicine, Hospital de Braga, Braga, Portugal
| | - Jorge Ribeiro
- Department of Urology, Hospital de Braga, Braga, Portugal
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Granulomatous Hepatitis Following Intra-Vesical Instillation of Bacillus Calmette-Guérin for Treatment of Bladder Cancer. Infect Dis Rep 2021; 13:611-618. [PMID: 34287340 PMCID: PMC8293128 DOI: 10.3390/idr13030057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/25/2021] [Accepted: 06/28/2021] [Indexed: 11/17/2022] Open
Abstract
Intra-vesical instillation of bacillus Calmette–Guérin (BCG) is an important treatment modality of superficial bladder cancer. It is usually well tolerated, although some adverse reactions can occur. One possible yet rare complication is granulomatous hepatitis, that is thought to be caused either by BCG infection or a hypersensitivity reaction to the bacillus. We present a case of a 79-year-old apparently immunocompetent patient who developed granulomatous hepatitis a few months after BCG administration for bladder cancer immunotherapy. It is important to notice that acid-fast smears and cultures are often negative, and these should not exclude diagnosis nor delay treatment. Our case highlights the importance of clinical suspicion and prompt initiation of appropriate treatment.
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8
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Gupta S, Singh B, Bhatt H, Singh S, Gupta S. A Case of Systemic Toxicity Related to Intravesical Bacillus Calmette-Guerin for the Treatment of Bladder Cancer. Cureus 2021; 13:e15321. [PMID: 34094785 PMCID: PMC8164525 DOI: 10.7759/cureus.15321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Intravesical administration of Bacillus Calmette-Guerin (BCG) has been utilized for the treatment of superficial bladder cancer for the past several decades. Though this treatment is well tolerated in general, both local and systematic side effects have been reported. We present a case of a patient who presented with systemic symptoms of fever with chills associated with leucopenia, thrombocytopenia, abnormal liver function tests (LFTs), and splenomegaly a few weeks after an episode of traumatic instillation of intravesical BCG. Though the mycobacterial cultures were negative, he was started on an anti-mycobacterial regimen empirically to which he responded and ultimately fully recovered.
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Affiliation(s)
- Sachin Gupta
- Hospital Medicine, Tower Health Reading Hospital, West Reading, USA
| | - Balraj Singh
- Hematology/Oncology, Saint Joseph's University Medical Center, Paterson, USA
| | | | - Sandeep Singh
- Internal Medicine, Indiana University School of Medicine, South Bend, USA
| | - Sorab Gupta
- Department of Hematology and Oncology, Bronx Lebanon Hospital, New York, USA
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9
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Headlam J, Wheeler A, Yuen K, Brierley E, Todd OM. Disseminated bacillus Calmette-Guérin (BCG): a cause of delirium in an older adult. J R Coll Physicians Edinb 2020; 50:152-155. [PMID: 32568287 DOI: 10.4997/jrcpe.2020.215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Intra-vesical Bacillus Calmette-Guérin (BCG) immunotherapy is an effective treatment for high-risk bladder cancer. Less well known is that fewer than 1% of patients receiving BCG treatment can develop disseminated BCG. The reaction can range from a mild flu-like illness to a systemic disorder with a fulminant course which in the most severe cases can lead to death. The diagnostic yield is low and diagnosis is often made after a comprehensive exclusion of more common causes of pyrexia of unknown origin. A high level of suspicion is therefore required in those who may be at risk. We report a case of disseminated BCG in an older patient for whom early involvement of his family was pertinent to determining the precipitant for delirium.
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Affiliation(s)
- John Headlam
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Alice Wheeler
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Keith Yuen
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | | | - Oliver M Todd
- Academic Unit for Ageing and Stroke Research University of Leeds, Bradford Teaching Hospitals NHS Foundation Trust Bradford BD9 6RJ, UK,
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10
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Green DB, Kawashima A, Menias CO, Tanaka T, Redelman-Sidi G, Bhalla S, Shah R, King BF. Complications of Intravesical BCG Immunotherapy for Bladder Cancer. Radiographics 2019; 39:80-94. [DOI: 10.1148/rg.2019180014] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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11
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12
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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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13
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Liaw F, Tan YY, Hendry D. Systemic BCG-osis following intravesical BCG instillation for bladder carcinoma. Clin Case Rep 2017; 5:1569-1572. [PMID: 29026546 PMCID: PMC5628231 DOI: 10.1002/ccr3.1129] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 06/22/2017] [Accepted: 07/08/2017] [Indexed: 11/06/2022] Open
Abstract
Intravesical instillation of Bacillus Calmette-Guérin (BCG) has been shown to be an effective form of immunotherapy for bladder cancer. This case report describes a patient who develops systemic BCG-osis following intravesical BCG instillation and demonstrates the importance of being aware of more severe complications associated with BCG immunotherapy.
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Affiliation(s)
- Frank Liaw
- Department of Urology Queen Elizabeth University Hospital Glasgow G51 4TF UK
| | - Yan Yu Tan
- Department of Gastroenterology Monklands Hospital Airdrie ML6 0JS UK
| | - David Hendry
- Department of Urology Queen Elizabeth University Hospital Glasgow G51 4TF UK
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14
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Llorenç V, Mesquida M, Molins B, González-Martín J, Sainz de la Maza M, Adán A. Bacillus Calmette–Guérin Infection and Cytotoxicity in the Retinal Pigment Epithelium. Ocul Immunol Inflamm 2016; 26:786-792. [DOI: 10.1080/09273948.2016.1265655] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Victor Llorenç
- Clínic Institute of Ophthalmology (ICOF), Hospital Clínic of Barcelona
| | - Marina Mesquida
- Clínic Institute of Ophthalmology (ICOF), Hospital Clínic of Barcelona
| | - Blanca Molins
- Biomedical Research Institute August Pi I Sunyer (IDIBAPS), Hospital Clínic of Barcelona, Barcelona, Spain
| | - Julián González-Martín
- Department of Clinical Microbiology & Parasitology (CDB-ISGlobal), Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain
| | | | - Alfredo Adán
- Clínic Institute of Ophthalmology (ICOF), Hospital Clínic of Barcelona
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Acute Hepatitis and Pneumonitis Caused by Disseminated Bacillus Calmette-Guérin Infection. ACG Case Rep J 2016; 3:130-2. [PMID: 26958569 PMCID: PMC4748205 DOI: 10.14309/crj.2016.23] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 10/06/2015] [Indexed: 11/17/2022] Open
Abstract
Intravesical instillation of Bacillus Calmette-Guérin (BCG) is the treatment of choice for superficial bladder carcinoma. We report a case of disseminated BCG infection in an early stage bladder cancer patient that initially presented with hepatitis followed by pneumonitis and sepsis. A complete clinical response was achieved in 14 days with anti-mycobacterial therapy and prednisolone. Disseminated BCG is a rare treatment complication and is likely a combination of direct infection and hypersensitivity.
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Intravesical BCG therapy as cause of miliary pulmonary tuberculosis. Urologia 2015; 83:49-53. [PMID: 26616461 DOI: 10.5301/uro.5000130] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2015] [Indexed: 11/20/2022]
Abstract
Immunotherapy with intravesical bacillus Calmette-Guérin (BCG) is considered the most effective adjuvant to endoscopic resection of bladder urothelial carcinoma in the therapeutic management of non-muscle invasive (NMIBC) at intermediate and high risk of recurrence and progression (pTa - pT1 and high-grade carcinoma in situ, CIS). Despite its proven efficacy, this type of treatment can determine local and systemic side effects of moderate or severe gravity, with the histological diagnosis of epithelioid granulomas in different organs, even in the absence of microbiological positivity of BCG. The immunotherapy with BCG is usually well tolerated and the virulence of the attenuated BCG is very low in immuno-competent patients, although only 16% of patients are able to receive all the instillations of the maintenance period (3 years) of treatment provided by the protocols, precisely because of side effects. Minor side effects usually resolve within a few hours or days. They develop in 3-5% of patients and usually consist of local infectious complications. Manifestations of BCG dissemination, such as vascular and ocular complications, are much less common, while BCG-disseminated infections, with granulomatous pneumonia or hepatitis present, are quite rare, representing 0.5-2% of the complications recorded. We present the clinical case of granulomatous lung and possibly liver infection caused by BCG in a patient aged 56 years being treated for several weeks with intravesical BCG for NIMBC pT1 high grade associated with CIS.
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Raffray L, Rivière P, Bonnet H, Duffau P, Longy-Boursier M. Hépatite granulomateuse révélant une infection disséminée à Mycobacterium bovis après BCG-thérapie intravésicale. Rev Med Interne 2015; 36:626-30. [DOI: 10.1016/j.revmed.2014.10.361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 05/21/2014] [Accepted: 10/21/2014] [Indexed: 10/24/2022]
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Larsen BT, Smith ML, Grys TE, Vikram HR, Colby TV. Histopathology of Disseminated Mycobacterium bovis Infection Complicating Intravesical BCG Immunotherapy for Urothelial Carcinoma. Int J Surg Pathol 2015; 23:189-95. [PMID: 25614462 DOI: 10.1177/1066896914567332] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Intravesical instillation of Bacillus Calmette-Guérin (BCG) is a mainstay of adjunctive therapy for superficial bladder cancer. Disseminated BCG infection ("BCG-osis") after this therapy is rare and potentially life-threatening; only isolated case reports detail the histopathologic findings thereof, few of which had a diagnosis confirmed by molecular testing. We report 3 additional cases of BCG-osis complicating BCG therapy, all confirmed by cultures and molecular assays, including the first cases of wedge biopsy-confirmed BCG pneumonia and BCG olecranon bursitis. When suggested by a relevant clinical history, recognition of randomly distributed granulomas in any organ should prompt consideration of BCG-osis and liberal performance of AFB stains, aided by targeted molecular assays. Physicians should maintain a high index of suspicion when miliary infiltrates arise after intravesical BCG instillation, and close multidisciplinary communication is essential. Pathologist awareness of this rare cause of granulomatous inflammation aids recognition of BCG-osis and facilitates prompt initiation of antimycobacterial therapy.
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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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Neuzillet Y, Rouprêt M, Larré S, Irani J, Davin JL, Moreau JL, Pfister C. Diagnostic et prise en charge des événements indésirables sévères survenant au décours des instillations endovésicales de BCG pour le traitement des tumeurs de vessie n’infiltrant pas le muscle (TVNIM). Presse Med 2013; 42:1100-8. [DOI: 10.1016/j.lpm.2012.10.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Revised: 10/12/2012] [Accepted: 10/23/2012] [Indexed: 11/28/2022] Open
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Demers V, Pelsser V. "BCGitis": A rare case of tuberculous epididymo-orchitis following intravesical Bacillus Calmette-Guérin therapy. J Radiol Case Rep 2012; 6:16-21. [PMID: 23372864 DOI: 10.3941/jrcr.v6i11.1100] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Tuberculous epididymo-orchitis is a rare complication of intravesical Bacillus Calmette-Guérin (BCG) therapy for urothelial cancer of the bladder. We present such a case, describe its sonographic appearance and review the literature. The difficulties in diagnosing this condition based on imaging alone, given the extensive overlap with the appearance of bacterial epididymo-orchitis, malignant testicular disease and testicular torsion, are discussed. Adequate knowledge of tuberculous epididymo-orchitis is of capital importance in order to ensure a proper diagnosis and treatment.
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Affiliation(s)
- Virginie Demers
- Department of Diagnostic Radiology, Jewish General Hospital, Montreal, Canada.
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Neuzillet Y, Rouprêt M, Wallerand H, Pignot G, Larré S, Irani J, Davin JL, Moreau JL, Soulié M, Pfister C. [Diagnosis and management of adverse events occuring during BCG therapy for non-muscle invasive bladder cancer (NMIBC): review of the Cancer Committee of the French Association of Urology]. Prog Urol 2012. [PMID: 23178094 DOI: 10.1016/j.purol.2012.04.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Intravesical BCG immuno-therapy with maintenance therapy is considered as the standard treatment for non-muscle invasive bladder cancer with high risk of recurrence and progression. In practice, adverse events (AEs) of BCG therapy could restrict its prescription by urologists. The aim of this article was to present a review of these AEs and of their management. MATERIALS AND METHODS A bibliographic research in French and English using Medline(®) and Embase(®) with the keywords "BCG", "bladder", "complication", "toxicity", "adverse reaction", "prevention" and "treatment" was performed. RESULTS The main mechanism of AEs of BCG are infectious (cystitis, fever), immuno-allergic (granulomatous prostatitis, epididymo-orchitis, and granulomatous reactions) and auto-immune (arthralgies, rash). Management of AEs is based on their pathophysiological mechanisms. Classifications of BCG therapy AEs based on clinical features allow to adapt their treatments. CONCLUSION The combination of antibiotics directed against BCG, steroid or non-steroidal anti-inflammatory medication and symptomatic treatment is currently the triad on which is set up the appropriate treatment of severe AEs. Reductions of BCG doses and ofloxacin medication after instillation decrease the frequency and severity of minor and moderate AEs. Severe or more than 7 days long infectious AEs, immuno-allergic AEs or auto-immune during more than 7 days impose cessation of BCG immuno-therapy.
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Affiliation(s)
- Y Neuzillet
- Service d'urologie, université de Versailles-Saint-Quentin-en-Yvelines, hôpital Foch, Suresnes, France.
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Granulomatous hepatitis, choroiditis and aortoduodenal fistula complicating intravesical Bacillus Calmette-Guérin therapy: Case report. BMC Infect Dis 2011; 11:260. [PMID: 21961922 PMCID: PMC3193172 DOI: 10.1186/1471-2334-11-260] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Accepted: 09/30/2011] [Indexed: 12/05/2022] Open
Abstract
Background Intravesical instillation of Bacillus Calmette-Guérin (BCG) is the treatment of choice for superficial bladder carcinoma. Complications of BCG therapy include local infections and disseminated BCG infection with multiple endorgan complications. Case Presentation We report a case of disseminated, post-treatment BCG infection that initially presented with granulomatous hepatitis and choroiditis. After successful anti-mycobacterial therapy and resolution of the hepatic and ocular abnormalities, the patient developed an acute upper gastrointestinal hemorrhage from an aortoduodenal fistula that required emergency surgery. The resection specimen revealed multifocal, non-caseating granulomas, indicating mycobacterial involvement. Conclusions This case highlights the varied end organ complications of disseminated BCG infection, and the need for vigilance even in immuno-competent patients with a history of intravesical BCG treatment.
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Arum CJ, Gederaas OA, Larsen ELP, Randeberg LL, Hjelde A, Krokan HE, Svaasand LO, Chen D, Zhao CM. Tissue responses to hexyl 5-aminolevulinate-induced photodynamic treatment in syngeneic orthotopic rat bladder cancer model: possible pathways of action. JOURNAL OF BIOMEDICAL OPTICS 2011; 16:028001. [PMID: 21361708 DOI: 10.1117/1.3536536] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Orthotopic bladder cancer model in rats mimics human bladder cancer with respect to urothelial tumorigenesis and progression. Utilizing this model at pT1 (superficial stage), we analyze the tissue responses to hexyl 5-aminolevulinate-induced photodynamic therapy (HAL-PDT). In comparison to untreated rats, HAL-PDT causes little change in tumor-free rat bladder but induces inflammatory changes with increased lymphocytes and mononuclear cell infiltration in rat bladders with tumor. Immunohistochemistry reveals that HAL-PDT is without effect on proliferating cell nuclear antigen expression within the tumor and increases caspase-3 expression in both normal urothelium and the tumor. Transmission electron microscopy reveals severe mitochondrial damage, formations of apoptotic bodies, vacuoles, and lipofuscin bodies, but no microvillus-formed niches in HAL-PDT-treated bladder cancer rats. Bioinformatics analysis of the gene expression profile indicates an activation of T-cell receptor signaling pathway in bladder cancer rats without PDT. HAL-PDT increases the expression of CD3 and CD45RA in the tumor (determined by immunohistochemistry). We suggest that pathways of action of HAL-PDT may include, at least, activations of mitochondrial apoptosis and autophagy, breakdown of cancer stem cell niches, and importantly, enhancement of T-cell activation.
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Affiliation(s)
- Carl-Jørgen Arum
- St. Olavs University Hospital Trondheim, Department of Surgery, N-7006 Trondheim, Norway.
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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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Olleros ML, Vesin D, Fotio AL, Santiago-Raber ML, Tauzin S, Szymkowski DE, Garcia I. Soluble TNF, but not membrane TNF, is critical in LPS-induced hepatitis. J Hepatol 2010; 53:1059-68. [PMID: 20813418 DOI: 10.1016/j.jhep.2010.05.029] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2009] [Revised: 05/27/2010] [Accepted: 05/29/2010] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS : Bacillus Calmette-Guérin (BCG) infection causes hepatic injury following granuloma formation and secretion of cytokines which renders mice highly sensitive to endotoxin-mediated hepatotoxicity. Tumor necrosis factor (TNF) is required for granuloma formation and is one of the most important cytokines in liver injury. TNF inhibitors are effective therapies for inflammatory diseases. However, clinical use of non-selective TNF inhibitors is associated with an increased risk of infections. This work investigates the differential roles of soluble TNF (solTNF) and membrane TNF (memTNF) in BCG infection, BCG/LPS- and D-GALN/LPS-induced liver injury. METHODS We have used both genetic and pharmacologic approaches and analyzed liver injury, TLR4, cytokine and iNOS activation induced by BCG, BCG/LPS and D-GALN/LPS. RESULTS BCG infection-induced liver injury is seen in wild-type mice but not in TNF(-/-), memTNF knock-in (KI), and sTNFR1-Fc transgenic mice. Severity of BCG-induced liver injury is correlated with BCG-granuloma number and hepatic expression of TLR4 and iNOS. In addition, protection from liver damage caused by BCG/LPS or D-GALN/LPS administration was observed in TNF(-/-), memTNF KI and sTNFR1-Fc transgenic mice. To extend the genetic findings, we then evaluated whether selective pharmacological inhibition of solTNF by dominant-negative (DN)-TNF neutralization and non-selective inhibition of solTNF and memTNF by anti-TNF antibodies and etanercept (TNFR2-IgG1) can protect the mice from liver injury. Both selective and non-selective inhibition of solTNF protected mice from BCG/LPS and D-GALN/LPS-induced liver damage. CONCLUSIONS These data suggest that memTNF is not mediating liver injury and that selective inhibition of solTNF sparing memTNF may represent a new therapeutic strategy to treat immune-mediated inflammatory liver diseases.
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Affiliation(s)
- Maria L Olleros
- Department of Pathology and Immunology, Centre Medical Universitaire (CMU), University of Geneva, Switzerland
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Geri G, Cacoub P. [Hepatic granulomas]. Rev Med Interne 2010; 32:560-6. [PMID: 20832918 DOI: 10.1016/j.revmed.2010.06.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2010] [Revised: 05/29/2010] [Accepted: 06/24/2010] [Indexed: 10/19/2022]
Abstract
Liver granulomas are histopathologically defined and associated with various liver and non-livers disorders. There are five main causes of liver granulomatosis: primary biliary cirrhosis, tuberculosis, sarcoidosis, B and C viral hepatitis, and drug related. In the other cases, not associated with an underlying systemic granulomatous disease, a systematic diagnostic approach should be used to identify less common etiologies. After a careful diagnostic work-up, a long-term follow-up of patients with undetermined liver granulomatosis is mandatory as it may be a presenting feature of liver lymphoma.
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Affiliation(s)
- G Geri
- Service de Médecine Interne II, Université Pierre-et-Marie-Curie-Paris 6, CNRS, UMR 7087, Hôpital Pitié-Salpêtrière, AP-HP, 47-83, Boulevard de l'Hôpital, 75013 Paris cedex 13, France
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Manfredi R, Dentale N, Piergentili B, Pultrone C, Brunocilla E. Tubercular disease caused by Bacillus of Calmette-Guérin as a local adjuvant treatment of relapsing bladder carcinoma. Cancer Biother Radiopharm 2010; 24:621-7. [PMID: 19877893 DOI: 10.1089/cbr.2009.0668] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Two (2) exemplary case reports of respiratory granulomatous infection caused by Bacillus of Calmette-Guérin (BCG), in patients who were repeatedly treated with local, intravesical adjuvant BCG therapy for a relapsing transitional bladder carcinoma, are outlined and discussed on the grounds of the cumbersome diagnostic and differential diagnostic process (especially when a prior tuberculosis and a concurrent chronic obstructive pulmonary disease are of concern), along with an updated literature revision. Only 4 cases of respiratory BCG-itis (pulmonary tuberculosis-like forms) have been reported, to date, to the best of our knowledge (2 of them following the bladder instillation of BCG). One (1) episode of ours represents the first described case with a dual, concomitant granulomatous localization of BCG-itis, also involving the genitourinary tract.
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Affiliation(s)
- Roberto Manfredi
- Department of Internal Medicine, Aging, and Nephrologic Diseases, Division of Infectious Diseases, Alma Mater Studiorum University of Bologna, S. Orsola-Malpighi Hospital, I-40138 Bologna, Italy.
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Shariat SF, Sfakianos JP, Droller MJ, Karakiewicz PI, Meryn S, Bochner BH. The effect of age and gender on bladder cancer: a critical review of the literature. BJU Int 2009; 105:300-8. [PMID: 19912200 DOI: 10.1111/j.1464-410x.2009.09076.x] [Citation(s) in RCA: 231] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
While patient age and gender are important factors in the clinical decision-making for treating urothelial carcinoma of the bladder (UCB), there are no evidence-based recommendations to guide healthcare professionals. We review previous reports on the influence of age and gender on the incidence, biology, mortality and treatment of UCB. Using MEDLINE, we searched for previous reports published between January 1966 and July 2009. While men are three to four times more likely to develop UCB than women, women present with more advanced disease and have worse survival rates. The disparity among genders is proposed to be the result of a differential exposure to carcinogens (i.e. tobacco and chemicals) as well as reflecting genetic, anatomical, hormonal, societal and environmental factors. Inpatient length of stay, referral patterns for haematuria and surgical outcomes suggest that inferior quality of care for women might be an additional cause of gender inequalities. Age is the greatest single risk factor for developing UCB and dying from it once diagnosed. Elderly patients face both clinical and institutional barriers to appropriate treatment; they receive less aggressive treatment and sub-therapeutic dosing. Much evidence suggests that chronological age alone is an inadequate indicator in determining the clinical and behavioural response of older patients to UCB and its treatment. Epidemiological and mechanistic molecular studies should be encouraged to design, analyse and report gender- and age-specific associations. Improved bladder cancer awareness in the lay and medical communities, careful patient selection, treatment tailored to the needs and the physiological and physical reserve of the individual patient, and proactive postoperative care are particularly important. We must strive to develop transdisciplinary collaborative efforts to provide tailored gender- and age-specific care for patients with UCB.
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Affiliation(s)
- Shahrokh F Shariat
- Division of Urology/Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA.
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Abstract
INTRODUCTION Age is now widely accepted as the greatest single risk factor for developing bladder cancer, and bladder cancer is considered as primarily a disease of the elderly. Because of the close link between age and incidence of bladder cancer, it can be expected that this disease will become an enormous challenge with the growth of an aging population in the years ahead. METHODS Using MEDLINE, a search of the literature between January 1966 and July 2007 was performed to describe normative physiologic changes associated with aging, elucidate genetic and epigenetic alterations that associate aging with bladder cancer and its phenotypes; and to characterize how aging influences efficacies, risks, side effects, and potential complications of the treatments needed for the various stages of bladder cancer. RESULTS We discuss influence of aging on host physiology, genetic and epigenetic changes, environmental influences, and host factors in the development and treatment of bladder cancer. Treatments with intravesical bacille Calmette Guerin, radical cystectomy, and perioperative chemotherapy are less well tolerated and have poorer response in elderly patients compared with their younger counterparts. Elderly patients face both clinical and broader institutional barriers to appropriate treatment and may receive less aggressive treatment and sub-therapeutic dosing. However, when appropriately selected, elderly patients tolerate and respond well to cancer treatments. CONCLUSIONS The decision to undergo treatment for cancer is a tradeoff between loss of function and/or independence and extension of life, which is complicated by a host of concomitant issues such as comorbid medical conditions, functional declines and "frailty", family dynamics, and social and psychologic issues. Chronological age should not preclude definitive surgical therapy. It is imperative that healthcare practitioners and researchers from disparate disciplines collectively focus efforts towards gaining a better understanding of what the consequences of bladder cancer and its treatments are for older adults and how to appropriately meet the multifaceted medical and psychosocial needs of this growing population.
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Affiliation(s)
- Shahrokh F. Shariat
- Division of Urology, Sidney Kimmel Center for Prostate and Urologic Cancer, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Matthew Milowsky
- Genitourinary Oncology Service, Sidney Kimmel Center for Prostate and Urologic Cancer, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Michael J. Droller
- Department of Urology, The Mount Sinai Medical Center, New York, NY, USA
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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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van den Boom R, Veldhuis Kroeze E, Klein W, Houwers D, van der Zanden A, Sloet van Oldruitenborgh-Oosterbaan M. Granulomatous Pneumonia, Lymphadenopathy, and Hepatopathy in an Adult Horse with Repeated Injection of BCG. J Vet Intern Med 2008; 22:1056-60. [DOI: 10.1111/j.1939-1676.2008.0104.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Heiner JG, Terris MK. Effect of advanced age on the development of complications from intravesical bacillus Calmette-Guérin therapy. Urol Oncol 2007; 26:137-40. [PMID: 18312931 DOI: 10.1016/j.urolonc.2007.04.005] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2006] [Revised: 04/16/2007] [Accepted: 04/16/2007] [Indexed: 11/18/2022]
Abstract
PURPOSE Advanced age is considered a risk factor for complications in patients receiving intravesical bacillus Calmette-Guérin (BCG) therapy. However, there is no clear delineation of BCG-related complication rates relative to patient age. MATERIALS AND METHODS We reviewed the clinical course of 58 consecutive men receiving maintenance BCG therapy from December 1999 to July 2004 for transitional cell carcinoma. Patients ranged in age from 51 to 92 years (mean 72.4). Age and BCG-related complications warranting discontinuance of therapy were documented. RESULTS In our patient population, 22 of 58 (37.9%) patients experienced complications. The complication rate for patients <70 years old on intravesical BCG maintenance therapy was 17.6%. Patients >or=70 years old had a complication rate of 48.6%. Excluding patients taking anticoagulants, the complication rate in patients age 70 and older was 53.3%. Patients who had complications (mean age 76.0 years) were significantly older than those who had no complications (mean age 70.3 years) (P < 0.00001). The peak incidence of complications occurred with the third BCG course. CONCLUSIONS Maintenance BCG therapy should be given with caution in patients over age 70 and should be avoided in patients over age 80. Elderly patients at high risk for TCC recurrence and progression may be better served with a single 6-week course of BCG or alternative intravesical agents. Anticoagulants may be somewhat protective against complications in elderly patients but have been shown to significantly decrease the effectiveness of intravesical BCG, further supporting the consideration of alternative agents.
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Affiliation(s)
- Jared G Heiner
- Sections of Urology, Augusta Veterans Affairs Medical Center and Medical College of Georgia, Augusta, GA 30912, USA
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36
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Gousseff M, Mechaï F, Lecuit M, Lortholary O. [Systemic granulomatosis of infectious origin]. Rev Med Interne 2007; 29:15-27. [PMID: 18054122 DOI: 10.1016/j.revmed.2007.09.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2007] [Accepted: 09/22/2007] [Indexed: 10/22/2022]
Abstract
PURPOSE Granulomatous diseases are defined by specific histological features, following the local recruitment of macrophages and lymphocytes. Many infections can lead to the development of granuloma. CURRENT KNOWLEDGE AND KEY POINTS Microorganisms responsible for granuloma include mainly mycobacteria, many viral and fungal species, as well as schistosoma in endemic areas. Nevertheless, almost all microorganisms can lead to granuloma, especially if their clearance needs macrophages pathway. New immunosuppressive drugs such as tumor necrosis factor antagonists are associated with a high risk of infectious granulomatous complications. All patients with granuloma must be carefully screened to find a potential underlying infection, since an immunosuppressive therapy could be otherwise considered. We here review the general diagnostic process with a specific glance to the main organs. FUTURE PROSPECTS AND PROJECTS Without clinical or epidemiological clue, diagnosis can be very tedious. New molecular tools now assist classical microbiological and histological techniques. Their specificity and sensitivity have recently been better characterized, and their use will probably increase in the near future for the diagnosis of infectious granuloma. They may also lead to discover new infectious aetiologies of granulomatous diseases formerly considered as idiopathic. We describe here the main microorganisms that can be responsible for granuloma, with a specific focus on the use of new diagnostic tools.
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Affiliation(s)
- M Gousseff
- Service des maladies infectieuses et tropicales, université René-Descartes-Paris-5, hôpital Necker-Enfants-Malades, centre d'infectiologie Necker-Pasteur, 149 rue de Sèvres, Paris cedex 15, France
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Sighinolfi MC, Micali S, De Stefani S, Mofferdin A, Ferrari N, Giacometti M, Bianchi G. Bacille Calmette-Guérin intravesical instillation and erectile function: is there a concern? Andrologia 2007; 39:51-4. [PMID: 17430423 DOI: 10.1111/j.1439-0272.2007.00762.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The aim of our study was to evaluate the effect of bacille Calmette-Guérin (BCG) therapy on erectile function in a cohort of male patients affected by non-muscle invasive bladder cancer. Thirty male patients undergoing BCG treatment for non-muscle invasive bladder cancer were enrolled in the study. Their mean age was 60.4 years. None of the patients had risk factors for erectile dysfunction (ED). All subjects underwent a BCG standard schedule therapy (once weekly instillation for 6 weeks). International Index of Erectile Function (IIEF-5) and International Prostate Symptom score (I-PSS) were addressed to the patients during the treatment schedule (at fourth or fifth instillation) and 1 month after the last instillation. The mean IIEF-5 score was 17.6 +/- 6.7 during therapy and 21.7 +/- 2.92 a month after the last instillation (P=0.008). Baseline ED and the association with lower urinary tract symptoms are variables significantly connected with post-treatment results (P=0.016 and 0.00 respectively) whereas the age seems not to be related to ED (P=0.256). No major side effects were recorded. It is concluded that BCG treatment is effective for prophylaxis of non-muscle invasive bladder cancer; however, it may induce a high incidence of ED. Although this effect is transient and reversible, erectile failure is another source of psychological distress that adversely affects the quality of life of men undergoing BCG treatment.
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Affiliation(s)
- M C Sighinolfi
- Department of Urology, University of Modena, Modena, Italy.
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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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Elmer A, Bermes U, Drath L, Büscher E, Viertel A. [Sepsis and multiple organ failure after BCG-instillation for bladder cancer]. Internist (Berl) 2004; 45:935-9. [PMID: 15138643 DOI: 10.1007/s00108-004-1205-8] [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: 11/28/2022]
Abstract
Local Bacillus Calmette-Guérin (BCG) immunotherapy is an effective and widely used treatment for superficial bladder carcinoma. Local side effects are frequent, whereas systemic side effects are rare, but more serious. Systemic BCG infection as a life-threatening complication of intravesical BCG instillation should be suspected in any patient who presents with persistent fever after BCG instillation for bladder cancer. A 62-year-old patient had been treated with 6 intravesical BCG instillations for recurrent, multifocal bladder carcinoma. 4 weeks after the last instillation, he presented with fever, malaise and scleral icterus. Laboratory tests revealed abnormal liver function tests, panzytopenia and signs of coagulation disorder. Bone marrow biopsy and liver biopsy showed noncaseating granulomas. Systemic BCG infection was suspected and antituberculous therapy combined with steroids was started. The patient developed severe sepsis and suffered from multiple organ failure. Despite partial improvement, the course was complicated by intracranial sinus thrombosis, and the patient died two month after admission.
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Affiliation(s)
- A Elmer
- Medizinische Klinik I und II, St. Josefs-Hospital, Wiesbaden
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40
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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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Gaya DR, Thorburn D, Oien KA, Morris AJ, Stanley AJ. Hepatic granulomas: a 10 year single centre experience. J Clin Pathol 2003; 56:850-3. [PMID: 14600131 PMCID: PMC1770104 DOI: 10.1136/jcp.56.11.850] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Epithelioid granulomas have been reported in 2-15% of unselected liver biopsies, with numerous underlying aetiologies described. However, all UK series were reported before identification of hepatitis C virus (HCV). AIM To evaluate the current aetiologies of hepatic granulomas and to assess the prognosis for the "idiopathic" group, in which all investigations for a recognised cause were negative or normal. METHODS A retrospective review of patient case notes between 1991 and 2001; all patients who had a liver biopsy at Glasgow Royal Infirmary revealing epithelioid granulomas had their case notes and liver biopsies reviewed and a standard proforma completed. RESULTS Over the study period, 1662 liver biopsies were performed. Hepatic granulomas were found in 63. Of those identified, 47 were female, with a mean age of 42 years (range, 17-81). Underlying aetiologies were as follows: primary biliary cirrhosis (PBC; 23.8%), sarcoidosis (11.1%), idiopathic (11.1%), drug induced (9.5%), HCV (9.5%), PBC/autoimmune hepatitis (AIH) overlap (6.3%), Hodgkin lymphoma (6.3%), AIH (4.8%), tuberculosis (4.8%), resolving biliary obstruction (3.2%), and other single miscellaneous causes (9.5%). Of the seven patients with idiopathic hepatic granulomas, one was lost to follow up, one died of stroke, and the remaining five were well with no liver related morbidity at a mean follow up of 6.2 years. CONCLUSIONS The aetiology of hepatic granulomas is broad ranging, with HCV an important cause in this population. Despite extensive investigations, a 10-15% of patients still had "idiopathic" hepatic granulomas. However, the prognosis for this last group appears to be excellent.
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Affiliation(s)
- D R Gaya
- Gastroenterology Unit, Glasgow Royal Infirmary, 84 Castle St, Glasgow, G4 0SF, UK.
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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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Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 29-1998. A 57-year-old man with fever and jaundice after intravesical instillation of bacille Calmette-Guérin for bladder cancer. N Engl J Med 1998; 339:831-7. [PMID: 9750077 DOI: 10.1056/nejm199809173391209] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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