Abstract | December 19, 2022
Granulomatous Reaction and Tuberculosis-Like Symptoms Induced by BCG Immunotherapy Treatment
Learning Objectives
- Diagnose a rare cause of granulomas and TB-like symptoms post-BCG vaccine administration for bladder cancer.
- Discuss risks of bladder cancer treatment in immunocompetent individuals. (3) Identify side effects of BCG vaccine cancer treatment.
Introduction: Bacillus Calmette-Guerin (BCG) vaccine is a live attenuated bacterial strain of Mycobacterium bovis used for the prevention of tuberculosis (TB). It is also an effective immunotherapy treatment for superficial bladder cancer. Although generally well tolerated, BCG-related infectious complications may occur after administration.These events are uncommon and have an incidence rate of less than 5%, With its wide range of presentations, from flu-like symptoms to severe fatal complications, this condition poses a challenge for the clinician. We report a case of disseminated BCG seen in an elderly patient with calcified granulomatous reactions and mimics of tuberculosis-like symptoms.
Case Presentation: A 70-year-old man was admitted to the hospital three weeks after receiving BCG treatment for bladder cancer and reported having fever and chills This was associated with nausea, vomiting, lightheadedness, confusion, and dry cough. On presentation patient was hypoxic with an 83% oxygen saturation. His other vitals were normal. Examination was normal. Basic labs such as CBC and BMP were normal. Blood cultures and sputum cultures were negative. On imaging both chest CT scan and x-ray revealed bilateral reticulonodular infiltrates. Bronchoalveolar lavage was performed and specimen revealed non-necrotizing granulomatous inflammation on right middle/upper lobe biopsies. Infectious disease was consulted and an extensive work up was completed to rule out other causes of granulomatous disease such as tuberculosis, histoplasmosis, and psittacosis. After ruling out several other causes a presumptive diagnosis of disseminated BCG infection was determined.
Management/ Outcome/and or Follow-up: Patient was started on Isoniazid with improvement of symptoms. Eventually rifampin and ethambutol were added to his regimen. There were no complications during the hospital stay. Patient was diagnosed with disseminated BCG secondary to BCG vaccine as symptoms occurred almost immediately after receiving treatment. The patient also had good response to medications that are traditionally used to treat tuberculosis which further supports our diagnosis. Once symptoms resolved, the patient continued management and surveillance of bladder cancer.
References:
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4740899/
- https://www.sciencedirect.com/science/article/pii/S2531043719301813?via%3Dihub
- https://www.rcpe.ac.uk/college/journal/disseminated-bacillus-calmette-guerin-bcg-cause-delirium-older-adult
