Granulomatous hepatitis, choroiditis and aortoduodenal fistula complicating intravesical Bacillus Calmette-Guérin therapy: Case report

Cindy Q Gao,Rozina Mithani,Lesley Dawravoo,John Antoine,Peter A Russo,Arvin Bhatia,Jack Leya,Claus J Fimmel,Felipe De Alba

doi:10.1186/1471-2334-11-260

Abstract

BackgroundIntravesical instillation of Bacillus Calmette-Guérin (BCG) is the treatment of choice for superficial bladder carcinoma. Complications of BCG therapy include local infections and disseminated BCG infection with multiple endorgan complications.Case PresentationWe report a case of disseminated, post-treatment BCG infection that initially presented with granulomatous hepatitis and choroiditis. After successful anti-mycobacterial therapy and resolution of the hepatic and ocular abnormalities, the patient developed an acute upper gastrointestinal hemorrhage from an aortoduodenal fistula that required emergency surgery. The resection specimen revealed multifocal, non-caseating granulomas, indicating mycobacterial involvement.ConclusionsThis case highlights the varied end organ complications of disseminated BCG infection, and the need for vigilance even in immuno-competent patients with a history of intravesical BCG treatment.

Highlights

Intravesical instillation of Bacillus Calmette-Guérin (BCG) is the treatment of choice for superficial bladder carcinoma
BCG therapy has become the treatment of choice for early stage transitional cell carcinoma of the bladder, with response rates ranging from 60%-94% - higher than any chemotherapeutic agent [2]
Disseminated BCG infections presenting as pneumonitis or granulomatous hepatitis, are rare: in the largest retrospective study reported to date, dissemination occurred in 0.7% of over 2,000 patients [4]

Summary

Introduction

Intravesical instillation of Bacillus Calmette-Guérin (BCG) is the treatment of choice for superficial bladder carcinoma. Conclusions: This case highlights the varied end organ complications of disseminated BCG infection, and the need for vigilance even in immuno-competent patients with a history of intravesical BCG treatment. Disseminated BCG infections presenting as pneumonitis or granulomatous hepatitis, are rare: in the largest retrospective study reported to date, dissemination occurred in 0.7% of over 2,000 patients [4]. We present a case of Mycobacterium bovis hepatitis and choroiditis occurring in an immunocompetent host more than one year after intravesical BCG treatment for bladder cancer.

Results

Conclusion