Miliary BCG–pneumonitis: a rare complication of intravesical BCG therapy

Česká verzia

Authors: Barbora Nechanská ¹; Jan Zaplatílek ¹; Richard Pabišta ¹; Olga Zadražilová ²
Authors place of work: Urologické oddělení, Oblastní nemocnice Mladá Boleslav, a. s., Mladá Boleslav ¹; Plicní oddělení, Oblastní nemocnice Mladá Boleslav, a. s., Mladá Boleslav ²
Published in the journal: Ces Urol 2019; 23(2): 140-148
Category: Case report

Summary

Adjuvant intravesical immunotherapy with Bacillus Calmette-Guérin (BCG) vaccine is an effective treatment for patients with high risk non-muscleinvasive bladder carcinoma. The therapy is usually well tolerated and accompanied only by local or mild systemic symptoms (dysuria, mild increase of body temperature). Life-threatening systemic complications (nephritis, pneumonitis, BCG - sepsis) occur rarely. Their diagnostics can be challenging due to non-specific symptoms and frequent negative findings in the urine, sputum or blood culture. A recommended treatment of systemic BCG infection is long-term antimicrobial therapy with chinolones and antituberculotics including the corticosteroids. Current knowledge of complications of intravesical BCG therapy comes mainly from individual case reports. We report a case of the patient with miliary BCG-pneumonitis. The aim of this work is to increase awareness of disseminated disease as a complication of intravesical BCG immunotherapy, discuss the diagnostic methods and emphasise early antitubercular therapy even without the demonstration of viable bacteria or positive cultures.

Keywords:

Bacillus Calmette-Guérin – disseminated pulmonary disease – immunotherapy – Mycobacterium bovis.

Zdroje

1. Babjuk M, Burger M, Compérat E, et al. 2018 EAU Guidelines on Non-Muscle-invasive Urothelial Carcinoma of the Bladder. Retrieved from: http://uroweb.org/guideline/non‑muscle‑invasive‑bladder‑cancer/ [1. 12. 2018].

2. Naudžiunas A, Juškaité R, Augryté A, el al. Tuberculosis Complications After BCG Treatment for Urinary Bladder Cancer. Medicina 2012; 48(11): 563–565.

3. Kaburaki K, Sugino K, Sekiya M, et al. Miliary Tuberculosis that Developed after Intravesical Bacillus Calmette‑Guerin Therapy. Internal Medicine 2017; 56(12): 1563–1567.

4. Colmenero JD, Sanjuan‑Jimenez R, Ramos B, Morata P. Miliary pulmonary tuberculosis following intravesical BCG therapy: case report and literature review. Diagnostic Microbiology and Infectious Disease 2012; 74(1): 70–72.

5. Brausi M, Oddens J, Sylvester R, et al. Side Effects of Bacillus Calmette‑Guérin (BCG) in the Treatment of Intermediate- and High‑risk Ta, T1 Papillary Carcinoma of the Bladder: Results of the EORTC Genito‑Urinary Cancers Group Randomised Phase 3 Study Comparing One‑third Dose with Full Dose and 1 Year with 3 Years of Maintenance BCG. European Urology 2014; 65(1): 69–76.

6. Pérez‑Jacoiste Asín MA, Fernández‑Ruiz M, López‑Medrano F, et al. Bacillus Calmette‑Guérin (BCG) Infection Following Intravesical BCG Administration as Adjunctive Therapy For Bladder Cancer. Medicine 2014: 93(17): 236–254.

7. Calleris G, Marra G, Corcione S, et al. Miliary pulmonary infection after BCG intravesical instillation: a rare, misdiagnosed and mistreated complication. Le Infezioni in Medicina 2017; 25(4): 366–370.

8. Batista M, Alves C, Boinas C, Camacho E. Tuberculosis Miliary in Patients Treated With Bacillus Calmette‑Guerin Immunotherapy: Case Report. Journal of Medical Cases 2017; 8(7): 233–235.

9. Vazquez‑Lavista L G, Flores‑Balcazar CH, Llorente L. The bacillus Calmette‑Guerin as immunomodulator in bladder cancer. Revista de Investigación Clínica 2007; 59: 146–152.

10. Elzein F, Albogami N, Saad M, et al. Disseminated Mycobacterium Bovis Infection Complicating Intravesical BCG Instillation for the Treatment of Superficial Transitional Cell Carcinoma of the Bladder. Clinical Medicine Insights: Case Reports 2016; 9.

11. Babjuk M, Soukup V. Intravezikální léčba povrchových nádorů močového měchýře. Urolog. praxi 2004; 3: 116–120.

12. Král M, Mucha Z, Študent V. Imunoterapie karcinomu močového měchýře. Onkologie 2013; 7(1): 30–34.

13. Moniruzzaman M, Islam S, Chandra S, Koli A, Hassan MJ. Tuberculosis and Deep Venous Thrombosis, a rare complication of a common disease: A case report. KYAMC Journal 2017; 6(1): 598–600.

14. Cobas Pas A, Garcia Tejedor JL, González Pineiro A, Fernández‑Villar A. Miliary tuberculosis due to BCG in an asymptomatic patient: initial onset or a condition not yet described? Tuberculosis miliar por BCG en un paciente asintomático: ¿afectación inicial o una entidad no descrita? Archivos de Bronconeumología 2010; 46(7): 394–395.

15. Dammert P, Boujaoude Z, Rafferty W, Kass J. Fever of unknown origin and pancytopenia caused by culture‑proven delayed onset disseminated bacillus Calmette‑Guerin (BCG) infection after intravesical instillation. Case Reports 2013; 2013: bcr2013008949.

16. 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 Biotherapy and Radiopharmaceuticals 2009; 24(5): 621–627.

17. Siatelis A, Houhoula DP, Papaparaskevas J, Delakas D, Tsakris A. Detection of Bacillus Galmette‑Guerin (Mycobacterium bovis BCG) DNA in Urine and Blood Specimens after Intravesical Immunotherapy for Bladder Carcinoma. Journal of Clinical Microbiology 2011; 49(4): 1206–1208.

18. Sheth JS, Belperio JA, Fishbein MC, et al. Utility of Transbronchial vs. Surgical Lung Biopsy in the Diagnosis of Suspected Fibrotic Interstitial Lung Disease. Chest 2017; 151(2): 389–399.

19. Tomasetti S, Wells A U, Costabel U, et al. Bronchoscopic Lung Cryobiopsy Increases Diagnostic Confidence in the Multidisciplinary Diagnosis of Idiopathic Pulmonary Fibrosis. American Journal of Respiratory and Critical Care Medicine 2016; 193(7): 745–752.

20. Sharp C, Mccabe M, Adamali H, Medford AR. Use of transbronchial cryobiopsy in the diagnosis of interstitial lung disease - a systematic review and cost analysis. An International Journal of Medicine 2017; 110(4): 207–214.

21. Delimpoura V, Samitas K, Vamvakaris I, Zervas E, Gaga M. Concurrent granulomatous hepatitis, pneumonitis and sepsis as a complication of intravesical BCG immunotherapy. Case Reports 2013; bcr2013200624.

22. Watts MR, Taylor PC, Sintchenko V, et al. Implications of Isoniazid Resistance in Mycobacterium bovis Bacillus Calmette‑Guerin used for Immunotherapy in Bladder Cancer. Clinical Infectious Diseases 2011; 52(1): 86–88.

23. Durek C, Rüsch‑Gerdes S, Jocham D, Böhle A. Sensitivity of BCG to Modern Antibiotics. European Urology 2000; 37(Suppl. 1): 21–25.

24. Dooley KE, Golub J, Goes FS, Merz WG, Sterling TR. Empiric Treatment of Community Acquired Pneumonia with Fluoroquinolones, and Delays in the Treatment of Tuberculosis. Clinical Infectious Diseases 2002; 34(12): 1607–1612.

25. Gonzalez OY, Musher DM, Brar I, et al. Spectrum of Bacille Calmette Guerin (BCG) Infection after Intravesical BCG Immunotherapy. Clinical Infectious Diseases 2003; 36(2): 140–148.

26. Fluorochinolony pro systémové a inhalační podání: riziko aneurysmatu aorty a aortální disekce [online]. Státní ústav pro kontrolu léčiv [cit. 17. 10. 2018]. Dostupné z: http://www.sukl.cz/leciva/informacni‑dopis‑fluorochinolony.

27. Fluorochinolonová antibiotika – omezení používání potvrzeno [online]. Státní ústav pro kontrolu léčiv [cit. 22. 11. 2018]. Dostupné z: http://www.sukl.cz/fluorochinolonova‑antibiotika‑omezeni‑pouzivani‑potvrzeno.

28. Rischmann P, Desgrandchamps F, Malavaud B, Chopin DK. BCG Intravesical Instillations: Recommendations for Side‑Effects Management. European Urology 2000; 37(suppl 1): 33–36.

29. Lamm DL, van der Meijden PM, Morales A, et al. Incidence and treatment of complications of bacillus Calmette‑Guerin intravesical therapy in superficial bladder cancer. Journal of Urology 1992; 147(3): 596–600.

30. Rodríguez F, Palou J, Martínez R, et al. Practical guideline for the management of adverse events associated with BCG installations. Archivos Españoles de Urología 2008; 61(5): 591–596.