A Case of Epididymo-orchitis after intravesical bacille Calmette-Guérin therapy for superficial bladder carcinoma in a patient with latent tuberculosis infection

Epididymo-Orchitis Mimicking Malignancy Resulting From Intravesical Bacillus Calmette-Guerin Immunotherapy for Bladder Cancer: An Attempt to Understand Pathophysiology, Diagnostic Challenges, Patients' Implications and Future Directions

This case report describes an 85-year-old patient who presented with painless, unilateral right testicular swelling of 2 months' duration. This raised the possibility of testicular cancer, especially given his recent treatment for bladder cancer, which included adjuvant intravesical bacillus Calmette-Guerin (BCG) therapy. This poses a diagnostic dilemma regarding tuberculosis (TB) of the testis, BCG complications or a true testicular malignancy. Biochemical markers and a computed tomography (CT) scan showed no evidence of malignancy or disseminated TB. A TB-ELISpot test was negative. An ultrasound of the testis revealed a hypoechoic soft tissue lesion measuring approximately 24 × 19 mm, with internal vascularity and calcifications, causing a bulge in the testicular capsule with probable extracapsular extension. Based on the clinical suspicion of a testicular tumor, a right inguinal orchidectomy was performed. Histopathologic examination revealed isolated tuberculous orchitis with focal epididymal involvement; the spermatic cord was not involved. Polymerase chain reaction (PCR) testing on the histological sample confirmed the presence of Mycobacterium bovis DNA. As a radical right orchidectomy had been performed, no abnormal tissue remained. Additionally, the CT scan showed no evidence of TB dissemination, and the patient was asymptomatic, so he was being closely monitored in the infectious disease clinic. Importantly, a urine culture became positive for TB, and he was started on antituberculosis medication. BCG-induced granulomatous epididymo-orchitis may rarely occur as a late complication following intravesical BCG therapy for superficial bladder cancer. In this case report, we attempted to understand the pathophysiology, diagnostic challenges, patient implications, and potential future research directions.

BCGitis after Bacille Calmette-Guerin intravesical administration from two referral centers: clinical characteristics and risk factors

Bacillus Calmette-Guerin (BCG) is commonly and safely used as intravesical instillation to treat bladder cancer. Adverse effects are widely described in case report and series with a broad range of clinical presentations known as "BCGitis". Moreover, microbiological identification is often inconclusive leading to diagnostic uncertainty and no standardisation of definitions is available. We retrospectively collected all cases of BCGitis (n=19) after BCG intravesical administration occurred in 2 major Italian hospitals in the last 10 years. Median age was 71.8 years and among comorbidities hypertension affected 60% of patients. The delay in the onset of symptoms was < one week and an inverse correlation was observed between the number of instillations and the time to the onset of symptoms. Moreover, a febrile presentation was the commonest clinical symptom (85%) and an interstitial or micronodular pattern at chest X-ray or CT scan was found positive in about 70% and 90% of cases, respectively. Larger cohorts are needed in order to inform clinically relevant algorythms for this uncommon disease.

Urogenital tuberculosis - epidemiology, pathogenesis and clinical features

Tuberculosis (TB) is the most common cause of death from infectious disease worldwide. A substantial proportion of patients presenting with extrapulmonary TB have urogenital TB (UG-TB), which can easily be overlooked owing to non-specific symptoms, chronic and cryptic protean clinical manifestations, and lack of clinician awareness of the possibility of TB. Delay in diagnosis results in disease progression, irreversible tissue and organ damage and chronic renal failure. UG-TB can manifest with acute or chronic inflammation of the urinary or genital tract, abdominal pain, abdominal mass, obstructive uropathy, infertility, menstrual irregularities and abnormal renal function tests. Advanced UG-TB can cause renal scarring, distortion of renal calyces and pelvic, ureteric strictures, stenosis, urinary outflow tract obstruction, hydroureter, hydronephrosis, renal failure and reduced bladder capacity. The specific diagnosis of UG-TB is achieved by culturing Mycobacterium tuberculosis from an appropriate clinical sample or by DNA identification. Imaging can aid in localizing site, extent and effect of the disease, obtaining tissue samples for diagnosis, planning medical or surgical management, and monitoring response to treatment. Drug-sensitive TB requires 6-9 months of WHO-recommended standard treatment regimens. Drug-resistant TB requires 12-24 months of therapy with toxic drugs with close monitoring. Surgical intervention as an adjunct to medical drug treatment is required in certain circumstances. Current challenges in UG-TB management include making an early diagnosis, raising clinical awareness, developing rapid and sensitive TB diagnostics tests, and improving treatment outcomes.

BCG orchitis

Intravesical immunotherapy with Bacillus Calmette-Guerin has been shown to decrease tumor recurrence and progression in urothelial carcinoma of the bladder. Its ubiquitous use is further substantiated by its low rates of complications. Our patient is a 63 year old male with a circuitous medical course who presents with epididymoorchitis and scrotal abscess after his second three week cycle of maintenance BCG prompting scrotal exploration which revealed a non-viable testicle and large scrotal induration with abscess. Pathological analysis and initial cultures were negative for mycobacterium but acid-fast cultures eventually demonstrated mycobacterium three months later.

Clinical Spectrum of Complications Induced by Intravesical Immunotherapy of Bacillus Calmette-Guérin for Bladder Cancer

Because of its proven efficacy, intravesical Bacillus Calmette-Guérin (BCG) immunotherapy is an important treatment for nonmuscle invasive bladder cancer at high risk of recurrence or progression. However, approximately 8% of patients have to stop BCG instillation as a result of its complications. Complications induced by BCG therapy can have a variety of clinical manifestations. These adverse reactions may occur in conjunction with BCG instillation or may not develop until months or years after BCG cessation. An essential step in the management complications arising from BCG is early establishment of diagnosis, particularly for distant, disseminated, and obscure infections. Therefore we reviewed the literature on the potential complications after intravesical BCG immunotherapy for bladder cancer and provide an overview on the incidence, diagnosis, and treatment modality of genitourinary and systemic BCG-induced complications.

Multiparametric ultrasound findings of tuberculous orchitis following bacillus Calmette-Guérin therapy

Granulomatous bacillus Calmette-Guérin (BCG) infection, both localized and disseminated, as a complication of intravesical therapy for transitional cell carcinoma of the bladder is a recognized but highly unusual phenomenon. We report the case of an 89-year-old gentleman with a history of bladder transitional cell carcinoma and subsequent intravesical BCG instillation of the bladder who presented to his general practitioner with a non-tender lump in his left testis. Histopathologic and microbiological evaluation of the subsequent orchidectomy specimen revealed granuloma formation secondary to BCG infection. The use of bubble contrast agents and elastography in ultrasound to evaluate focal testicular lesions is a relatively novel concept, and we aim to highlight the imaging features of testicular BCG infection using these techniques.