BCG Sepsis Following Intravesical BCG Administration for the Treatment of Bladder Cancer

Abstract

膀胱がんのBCG療法が、BCG sepsisを起こす話 シドフォビルの膀胱内注入で引用 INTRODUCTION: BCG (Bacillus Calmette-Guerin) is a live attenuated strain of Mycobacterium Bovis, used as intravesical immunotherapy for superficial bladder cancers. Complications include cystitis, hepatitis, pneumonitis, arthritis, osteomyelitis, and rarely sepsis. We present the case of a patient with sepsis secondary to disseminated BCG infection after treatment for bladder cancer. CASE PRESENTATION: 78-year-old male with history of bladder cancer presented to the ER with SOB after his fourth treatment with intravesicul BCG. The symptoms had started shortly after the treatment and had progressively worsened until presentation. In ED he was febrile, hypotensive and tachycardic and later on deveoped septic shock. He was fluid resuscitated and briefly placed on vasopressors. Laboratory values showed in Tab1 All cultures were negative and series of abdominal imaging failed to show hepatobiliary pathology. Liver biopsy showed no granulomatous changes. Subsequently bone marrow and transbronchial lung biopsy were performed, showed noncasiating granulomas. The patient continued to be septic without a clear source. BCG Sepsis was suspected and treatment was initiated. His sympyoms, lung infiltrate and transaminities resolved within 4 weeks of M Bovis treatment. DISCUSSION: Intravesical BCG instillations are used as an adjunct in the treatment of non-invasive urothelial bladder cancer. Initial treatment includes complete cystoscopic resection of visible bladder tumor followed by adjuvant intravesical therapy. Disseminated BCG has also been described in cases reports of patients receiving IM BCG for the prevention of tuberculosis. The pathophysiology of disseminated BCG is not fully understood, the main theories being a hypersensitivity reaction to the organism versus a re-activation of the mycobacterium, or a combination of both. Many case reports describe the presence of granulomas and the absence of organisms which favor the hypersensitivity theory, and some case reports describe the recovery of viable organisms, favoring the reactivation theory. The non-caseating granulomas found in the bone and lung biopsies which are characteristically found in many of the case reports of disseminated BCG were helpful in pointing to the diagnosis. CONCLUSIONS: Disseminated BCG is a rare but serious complication of intravesical BCG administration for the treatment of bladder cancer. This diagnosis should always be considered in a bladder cancer patient who presents with systemic signs of infection or sepsis after being treated with intravesical instillation of BCG.