Fever of Unknown Origin in a Patient Administered With Bacillus Calmette-Guérin (BCG) to Treat Urothelial Vesical Carcinoma in Situ

Good old BCG – what a century‐old vaccine can contribute to modern medicine

MAINTENANCE BACILLUS CALMETTE-GUERIN IMMUNOTHERAPY FOR RECURRENT TA, T1 AND CARCINOMA IN SITU TRANSITIONAL CELL CARCINOMA OF THE BLADDER: A RANDOMIZED SOUTHWEST ONCOLOGY GROUP STUDY

Intravesical therapy for bladder cancer

Bacillus Calmette Guérin (BCG) vaccination use in the fight against COVID-19 - what's old is new again?

A Mycobacterium tuberculosis complex organism was isolated unexpectedly from blood cultures obtained from a 3-year-old child succumbing to HIV-associated cardiomyopathy at our hospital. Biochemical studies speciated the isolate as Mycobacterium bovis. Because the child had been immunized with Bacillus Calmette-Guérin (BCG) at birth, we sought to determine whether the isolate recovered from the blood before death was BCG or a pathogenic strain of M. bovis. Our report focuses on three issues: the methods of differentiation of the M. tuberculosis complex strains; the factors contributing to possible underdiagnosis of disseminated infections; and the need for additional studies to determine the true incidence of dissemination in BCG-vaccinated HIV-infected children. Case report. A Brazilian child, immunized with BCG at birth, was adopted by an American expatriate family at 1 week of age. Medical history included developmental delay, recurrent otitis media and failure to thrive. At 15 months of age he was found to be infected with HIV by serologic testing in Brazil (not repeated at our hospital). Zidovudine therapy was begun at the time of diagnosis. Approximately 1 month before arrival in the United States for parental job relocation at 3 years of age, the patient developed increasing dyspnea and signs of cardiac failure. Physical examination on admission to Vanderbilt Children's Hospital in 1993 revealed an afebrile child with a heart rate of 160 and a respiratory rate of 32, accompanied by intercostal retractions and nasal flaring. Pulmonary congestion, cardiomegaly, hepatomegaly and generalized adenopathey were present. No cutaneous lesions or splenomegaly were seen. Chest roentgenogram revealed massive cardiomegaly, severe pulmonary congestion and bilateral pleural effusions. Despite vigorous diuresis and digitalization, the child expired. Request for autopsy was denied. Postmortem Bactec® blood cultures were obtained to evaluate the possibility of disseminated Mycobacterium avium-intracellulare infection. These cultures grew a mycobacterial organism confirmed by DNA probe (Gen-Probe, San Diego, CA) to be M. tuberculosis complex. The rarity of this observation led the clinicians to pursue vigorously a more complete identification of the organism. Conventional phenotypic studies performed in the laboratories of the Tennessee State Health Department revealed the organism to be niacin- and nitrate reduction-negative, findings consistent with M. bovis or BCG. Mycolic acid characterization by high performance liquid chromatography (HPLC) at the Centers for Disease Control, Atlanta, GA, revealed a distinctive chromatogram unique to TMC 1022, a Russian BCG strain.1 Molecular characterization was also performed (by Richard Frothingham, Duke University) by a recently described method of sequence-based strain differentiation.2 The patient strain, like those of other BCG strains, belonged to the MEDIUM-C® sequevar. Strains of M. tuberculosis and non-BCG M. bovis isolates belong to other sequevars. Discussion. With improved methods to isolate mycobacteria from the blood, disseminated infections in HIV-infected patients are more commonly recognized. Although the majority of mycobacterial isolates in the United States are M. avium-intracellulare strains, M. tuberculosis complex strains are also recovered and are confirmed by gene probe technology. Because the M. tuberculosis complex contains the four species, M. tuberculosis, Mycobacterium bovis, Mycobacterium microti and Mycobacterium africanum, which are closely related genetically, strain differentiation can be difficult. Biochemical methods can be suggestive but are not definitive. Antimicrobial susceptibility testing can offer some assistance since BCG is resistant to PZA and M. tuberculosis is generally susceptible. Separation of BCG from M. tuberculosis and M. bovis by HPLC of mycolic acids has been very useful.1 Molecular markers, such as the insertion sequence, IS6110, have been extremely important in differentiating strains of M. tuberculosis for epidemiologic purposes, but have not been as useful for other members of the M. tuberculosis complex since they share common IS6110 patterns.3 Another insertion sequence, IS1081, has been used successfully to differentiate M. bovis strains of BCG and non-BCG origin and may be used more commonly in the future to distinguish between these strains.4 Finally sequence-based analysis has been helpful in distinguishing these strains.2 Biochemical, HPLC and sequence-based analysis confirmed that the strain isolated from our patient was BCG. BCG vaccines are live attenuated mycobacterial strains originating directly or indirectly at different times from the original Institut Pasteur strain which was itself derived from a virulent bovine tubercle bacillus by 230 passages on glycerol-bile-potato medium in the years between 1908 and 1921. The earliest daughter strains were the Brazilian, Russian, Romanian and Swedish strains which were all derived between 1925 and 1928. The descendants of these four strains are similar in their mycolic acid profiles, in their pattern of protein synthesis and in the possession of two copies of IS6110.5 After that time other BCG strains were derived, such as the Japanese, Danish, Pasteur and Tice strains, having different HPLC patterns, different secreted proteins and a single copy of IS6110. The HPLC pattern obtained from our patient immunized in Brazil appeared identical with that of a Russian BCG strain, suggesting a common ancestry of both strains. Attempts to more fully characterize the lineage of the BCG strain administered to our patient were unsuccessful. Live BCG vaccine is given to newborn infants throughout the developing world. Many of these areas have high rates of tuberculosis and HIV infection. It is remarkable that only 14 cases of disseminated BCG in HIV-infected patients had been reported previously in the literature,6-17 with 7 of the previously reported cases in children (Table 1).6, 7, 11, 13, 15, 16 Symptoms seen in these patients included fever, adenopathy, weight loss and organomegaly, although some of the reports provided few clinical details. Before our report definitive biochemical and molecular confirmation of the BCG strain had been made in only one patient.6 Because our patient was afebrile and had symptoms that could all be explained by HIV cardiomyopathy, we had no clinical suspicion of disseminated BCG infection. It was fortuitous that the blood culture was done. However, it is likely that many patients receiving BCG, whether infected with HIV or not, have transient bacteremia with BCG. In fact in a report of autopsy findings in 26 BCG-vaccinated non-HIV-infected individuals dying of causes not related to BCG, granulomas were seen in distant organs at least 2 to 3 years after vaccination without any clinical signs.18 These data suggest that hematogenous spread of BCG from the site of vaccination is common. It is also possible that some of the cases reported as disseminated BCG might actually be infections with other species of the M. tuberculosis complex, such as M. bovis or M. tuberculosis. In a large series of patients with M. bovis infections, Danker et al.19 described eight cases of disseminated M. bovis infections in HIV-infected patients. Isolation of M. tuberculosis from blood cultures from HIV-infected patients has also be shown in 26 to 41% of patients with clinical tuberculosis, a rate much higher than reported for non-HIV-infected patients.20, 21 This case clearly demonstrates the need for definitive identification of mycobacterial isolates obtained from HIV-infected individuals with the most sophisticated methods of HPLC, molecular markers and sequence-based analysis. In areas of the world where such techniques are unavailable, isolates should be sent to reference laboratories for this purpose. Finally larger prospective studies utilizing mycobacterial blood cultures obtained at regular intervals in BCG-immunized HIV-infected infants appear warranted. Only in this way can the true incidence of disseminated BCG infection and its impact on HIV-infected infants and children be determined. Currently the World Health Organization and UNICEF policies support the routine immunization of asymptomatic infants in countries with high rates of both HIV and tuberculosis infection.22 For children living in the United States a joint communication from two Centers for Disease Control and Prevention advisory groups, the Advisory Council for the Elimination of Tuberculosis and the Advisory Council for Immunization Practices, has recommended that BCG vaccination should not be given to HIV-seropositive or known infected infants and children, even if the risk of tuberculosis is high. While additional studies are in progress, we endorse both of these policies. Acknowledgment. Work was supported by NIH Grants AI37871 (KME) and AI-35250 (DSK). Kathryn M. Edwards, M.D.; Douglas S. Kernodle, M.D. Division of Infectious Diseases Departments of Pediatrics and Medicine Vanderbilt University Medical Center Nashville, TN

Léon Charles Albert Calmette and Jean-Marie Camille Guérin

EFFECTS OF ACETYLIC SALICYLIC ACID AND PENTOXIFYLLINE ON THE EFFICACY OF INTRAVESICAL BCG THERAPY IN ORTHOTOPIC MURINE BLADDER CANCER (MB49)

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel human coronavirus12, has infected close to 22 million people and killed about 0.77 million people in more than 200 countries (as of August 18, 2020)3. Given the fact that SARS-CoV-2 poses an unprecedented threat in terms of transmission and mortality, the World Health Organization has geared up efforts to control, contain and prevent coronavirus disease 2019 (COVID-19). The development of a vaccine has a high attrition rate and involves linear steps of clinical trial and evaluation. For those systems that have been tested on humans previously, parallel testing can involve both animals and phase I human trials4. Although some of the potential COVID-19 vaccine candidates have made it through phase I and II clinical trials, mass availability of COVID-19 vaccine could only be possible by 20215. Repurposing of the existing drugs and development of vaccines are thus feasible options to protect people from the severity of the COVID-19 pandemic. Host immunity plays a crucial role in the elimination of viruses and prevents disease progression. Strategies to boost the same, especially during incubation and non-severe phase of SARS-CoV-2 infection, can be a viable option to check disease severity. Bacille Calmette-Guerin (BCG) induces non-specific protection against a range of bacteria and viruses6. Therefore, it is worth exploring the immunostimulatory and protective potential of BCG against SARS-CoV-2 infection. BCG is a live attenuated strain of Mycobacterium bovis widely used as a vaccine for the prevention of tuberculosis (TB) caused by Mycobacterium tuberculosis (Mtb). Intradermal/subcutaneous delivery of BCG vaccine protects against disseminated forms of TB in children and provides variable protection against pulmonary TB in adults78. Recent reports suggest that the efficacy of BCG can be improved by selective delipidation of the outer membrane or alternative route of delivery910. BCG immunization elicits non-specific immunological outcomes that prevent general infections and reduce mortality caused by unrelated pathogens6, besides amplifying responses to other paediatric vaccines11. BCG has long been employed as an immunotherapeutic agent or adjuvant for preventing recurrence and progression of bladder cancer12. A recent report13 suggests that the potential of BCG in preventing SARS-CoV-2 infection may be validated among hyper-susceptible population subset such as the front line healthcare personnel and the elderly people. Clinical trials to test the efficacy of BCG in boosting the immune system against SARS-CoV-2, have been initiated in the Netherlands (NCT04417335), Australia (NCT04327206) and Columbia (NCT04362124) (http://www.clinicaltrials.gov). Host pattern recognition receptors (PRRs), expressed by innate immune cells, interact with pathogen-associated molecular patterns (PAMPs) of viruses and initiate innate immune response against viral pathogens. Many of the PAMPs are common among different species of bacteria and viruses. Multiple families of PRRs such as NOD-like receptors, RIG-l-like receptors and toll-like receptors detect viral proteins, which in turn induce interferons and cytokines, aiding in the elimination of the virus. It is tempting to speculate that immune response against BCG may cross-recognize SARS-CoV-2-associated PAMPs and confer immunity against this infection. Prior immunization with BCG or re-vaccination with BCG in adults can induce 'trained immunity' (innate immune memory), a term used to describe the possible mechanism(s) underlying heterologous protection induced by BCG against non-mycobacterial antigens. The trained immunity is a kind of conditioning of the innate immune cells, mainly monocytes/macrophages/natural killer cells, to undergo specific epigenetic changes (including de-methylation/de-acetylation) in the genes associated with mounting a robust and non-specific immune response14, resulting in a heightened recall response by primed innate immune cells upon a second encounter to the same/different/broad range of unrelated microbial PAMPs. The degree of immunological response has been correlated with the chromatin accessibility at the genome regions controlling immune response15. Regulatory RNA species, including long non-coding RNAs and microRNAs, have also emerged as the regulators of epigenetic reprogramming of innate immune cells, besides substantial rewiring of host metabolic landscape with a predominant shift from oxidative phosphorylation to glycolysis14. In humans, limited documentation exists on the impact of unintended protective effects of BCG against viral infections. BCG-immunized mice exhibited higher resistance to influenza viral infection challenge as compared to the unvaccinated mice16. Arts et al17 reported significantly low levels of viraemia in BCG-vaccinated human volunteers challenged with experimental yellow fever virus (attenuated strain), and the BCG-induced protection correlated with increased production of interleukin (IL)-1β. Consistent with these studies, BCG re-vaccination induced innate and adaptive immune responses in adult TB patients18 also suggest its utility to renew response against mycobacteria and other unrelated pathogens possibly via induction of trained immunity. MTBVAC, a live attenuated Mtb vaccine strain, provides long-term non-specific immunological effect on innate trained immunity in addition to adaptive immune response19. Kleinnijenhuis et al20 have demonstrated that the levels of pro-inflammatory cytokines such as IL-1β, tumour necrosis factor-α and IL-6 remain elevated up to one year post-BCG vaccination and subsequently waned. In line with previous reports showing beneficial non-specific immune potentiating effects of BCG vaccine, one can logically speculate that BCG vaccination (or re-vaccination in countries with universal BCG immunization) may lead to improved clinical outcomes in viral or other respiratory tract infections, including SARS-CoV-2. A recent ecological study has suggested that countries where BCG is part of the immunization schedule, the extent of mortality and morbidity due to COVID-19 is significantly reduced, and may be able to contain the spread of SARS-CoV-2 better than those countries which did not have BCG vaccination21. The differences in the number of SARS-CoV-2-infected cases between countries adhering to the universal BCG vaccination policy and those where universal BCG vaccination is not a policy were evaluated, based on the data of COVID-19 cases across the globe (https://www.coronavirus.jhu.edu/map.html) and BCG vaccination status from BCG World Atlas database22. It was observed that in countries where BCG was a part of the immunization schedule, COVID-19 cases/100,000 population were almost similar to those where BCG was not a part of universal vaccination schedule (Figure A). However, the cause-specific death rate/100,000 population was significantly lower in countries having BCG immunization policy, compared to those where a universal BCG vaccination policy did not exist (Figure B). This suggests that BCG vaccination-induced non-specific immunity may be associated with the mitigation of disease severity in COVID-19-pandemic areas.Figure: Scatter plot showing differences in the number of confirmed cases of SARS-CoV-2 infection (A) and cause-specific death rate (B) per 100,000 population between countries having universal BCG vaccination policy (BCG+ countries) and countries that do not have a universal BCG vaccination policy (BCG− countries). The description of the different colour and symbols is as follows: European countries (sky blue square), Asian countries (red circle), Middle East countries (yellow square), African countries (brown diamond), North American countries (purple upright triangle), South American countries (green inverted triangle) and Australia (grey hexagon). The countries represented in the graph are those with >3000 confirmed COVID-19 cases, as of July 9, 2020. The significance of the two data sets was tested using unpaired, non-parametric Student's t test using GraphPad Prism software version 6.7 (San Diego, CA, USA) and is shown on the top of the plot (ns, non-significant; *** P<0.001).Source: http://www.bcgatlas.org; http://www.gisanddata.maps.arcgis.com.We hypothesized that prior BCG vaccination status was associated with the extent of the COVID-19 epidemic. Because COVID-19 cases started or peaked at different time periods and the infection or death rate stabilized differently among various countries, it posed a limitation to the current study. Our results, therefore, are a pointer rather than final conclusion about the role of BCG in arresting the COVID-19 pandemic. To have a more definitive picture, the association of BCG vaccination with the protection or recovery from the SARS-CoV-2 infection must be reinforced with the data available at the individual level. A more comprehensive comparison of BCG-vaccinated individuals on the basis of age at the time of vaccination or re-vaccination may provide critical evidence and logical conclusion for ascertaining the use of BCG in the prevention of COVID-19. A significant amount of work has been done to engineer BCG to enhance its immune-boosting and protective properties. VPM1002, a genetically engineered BCG, exhibits improved immunogenicity23, has completed phase I clinical trial in Germany (NCT00749034) and phase II clinical trial in South Africa (NCT01479972) and is currently in phase III clinical trials in India (NCT03152903) for assessing the prevalence of TB recurrence in drug-treated individuals. A separate phase III trial of VPM1002 (NCT04387409) has also been initiated to assess healthcare professionals' absenteeism during the COVID-19 pandemic in Germany (Table). VPM1002 was engineered to survive within the phagosome (unlike BCG), and was equipped with listeriolysin (from Listeria) to perforate phagosomal membrane. VPM1002 has also been reported to prevent recurrence of bladder tumours, highlighting its non-specific benefits. Another recombinant BCG strain overexpressing STING (stimulator of interferon genes)-agonist has shown significantly augmented pro-inflammatory cytokine response and protective efficacy in mice and guinea pigs challenged with Mtb24.Table: Role of bacille Calmette-Guerin (BCG), recombinant BCG, attenuated Mycobacterium tuberculosis (Mtb) or M. indicus pranii (MIP) as immunotherapy and possible intervention against COVID-19Alternatively, immunogenic components of BCG, such as muramyl dipeptide, can also be tested as an adjunct therapy for immune stimulation in those at high-risk to be affected with COVID-19. In addition to being broadly protective, safe and immunogenic, BCG is cost-effective, easy to produce in bulk and, therefore, may be suitable in terms of both availability and affordability. However, before exploiting BCG-induced training of innate immune responses against infections by unrelated pathogens, several potentially confounding factors such as host genetic polymorphisms, endemicity to other viral/bacterial infections and route of immunization need to be examined. Of particular note is the association of BCG vaccination, with some adverse effects such as formation of abscess and lymphadenitis and local cutaneous inflammation2829. Intravesical BCG therapy for the treatment of non-invasive bladder cancer has resulted in short period of fever and discomfort in majority of the patients30. Clinical trials for testing the efficacy of BCG, administered (or re-administration) through a conventional or alternate route910, against SARS-CoV-2 can be initiated as an interim intervention against COVID-19. The pros and cons of diverting the stock of BCG as a temporary measure for non-specific protection till actual vaccines for COVID-19 are commercially available must be deliberated upon, as it should not limit the supply of BCG for the people in TB-infected endemic regions. Therefore, it is important to explore agents similar to BCG that can act as immunomodulator. In this regard, it is equally tempting to suggest another mycobacteria discovered in India, Mycobacterium indicus pranii (MIP)31, earlier known as Mw. MIP has been found to be a strong immunomodulator with proven utility as an adjunct therapy for leprosy treatment25, category II TB26 in humans and in inducing tumour regression27, and possibly functions by invoking trained immunity (Table).

MURINE IL-2 SECRETING RECOMBINANT BACILLUS CALMETTE-GUÉRIN AUGMENTS MACROPHAGE-MEDIATED CYTOTOXICITY AGAINST MURINE BLADDER CANCER MBT-2

Disseminated BCG infection is a very rare complication of BCG vaccination. This study presents 11 patients with such complication. The underlying disease in eight of the 11 patients was primary imm...

BCG (Bacillus Calmette-Guérin) vaccine is a widely used vaccine with the recommendation of World Health Organization to protect children against miliary tuberculosis (TB) and TB meningitis. Severe side effects related to this vaccine mostly manifest in the presence of underlying immunosuppressive disease. In this report, an infant case with unknown chronic granulomatous disease (CGD) who developed disseminated BCG infection after administration of BCG vaccine, was presented. High fever, left axillary lymphadenopathy and hepatosplenomegaly have developed in a 3-month 28-day female infant, without a known health problem, following BCG vaccination. The acid-fast bacilli (ARB) was isolated from the material of excised lymph node cultivated in Löwenstein-Jensen medium, and the isolate was identified as Mycobacterium bovis. Mycobacterium tuberculosis complex DNA was detected in the axillary lymph node sample by polymerase chain reaction. Anti-tuberculous treatment included 20 mg/kg of rifampicin+10 mg/kg of isoniazid+15 mg/kg of ethambutol+30 mg/kg of streptomycin was started. The patient was then further evaluated for immunodeficiency and on the basis of the results of dihydroamine and LAD (lymphocyte adhesion defect) tests, diagnosed as autosomal recessive CGD. Based on the anamnesis, there was no known immunodeficiency history both in the case during neonatal period and her family members. Interferon-gamma therapy, which is recommended for the patients with CGD living in endemic areas, was initiated. Our patient's fever dropped at the 15th day of anti-tuberculosis treatment, and she was discharged on the 35th day and continued to receive treatment at home. The patient was followed up at outpatient clinic and had no additional complaints; her hepatosplenomegaly was back to normal at the third month. As a result, since BCG vaccine is contraindicated in CGD carriers, newborns with a family history of CGD should be immunologically examined and BCG vaccine should be avoided until the results are obtained. In addition, newborns without a family history, diagnosed as disseminated mycobacterial infection following BCG vaccination, should be evaluated for an underlying immunodeficiency condition.

AUTOCRINE IL-6 PRODUCTION BY HUMAN TRANSITIONAL CARCINOMA CELLS UPREGULATES EXPRESSION OF THE α5β1 FIBRONECTIN RECEPTOR

Contribution of Transmembrane Tumor Necrosis Factor to Host Defense against Mycobacterium bovis Bacillus Calmette-Guerin and Mycobacterium tuberculosis Infections

Immunization With a Bivalent Adenovirus-vectored Tuberculosis Vaccine Provides Markedly Improved Protection Over Its Monovalent Counterpart Against Pulmonary Tuberculosis

Doctor Albert Calmette 1863–1933: founder of antivenomous serotherapy and of antituberculous BCG vaccination