Klebsiella pneumoniae invasive infection in an immunocompetent patient

Abstract

Immunotherapywith BCG, a live attenuated strain ofMycobacterium bovis, is a well known and effective therapy in the treatment of superficial bladder cancer. Although considered a relatively safe treatment, local and systemic complications may occur. Late disseminated infection manifested 1 year or more after the first BCG intravesical instillation is rare, occurring in 1% of the patients. There are less than 50 cases of late-presentation infection described in the literature. The authors present the case of an 80 year-old male patient with a known diagnosis of bladder carcinoma. Two years earlier he underwent transurethral resection of the bladder tumor followed by intravesical BCG instillation therapy. His past medical history was remarkable for several comorbidities namely chronic kidney disease on hemodialysis treatment. The patient presented with asthenia, occasional low grade fever and night sweats for the last 12 months. These complaints were attributable to urinary tract infections and the patient was started on quinolones for several times for the last months. An isolated generalized seizure was reported during a previous hospital course 1 month earlier. His bladder cancer remained in remission. On physical examination the patient was cachectic and had no adenopathies or meningeal signs. Laboratory investigation showed pancytopenia. Computed tomography scan of the abdomen revealed hepatomegaly, splenomegaly and several abdominal aorta aneurysms. The bone marrow biopsy showed noncaseating granulomas. A lumbar puncture was made and the cerebrospinal fluid analysis revealed pleocytosis with a lymphocyte predominance, diminished glucose levels and elevated protein levels and adenosine deaminase. M. bovis was isolated in the bone marrow and bronchoalveolar lavage cultures by polymerase chain reaction assay was performed confirming the diagnosis of M. bovis disseminated infection. The patient died 2 weeks after antituberculous therapy was started. This case illustrates a rare late complication of intravesical BCG instillation. We highlight the multisystemic infection involvement (meninges, lung, bone marrow and abdominal aorta walls) and the isolation of M. bovis in two distinct locations (lung and bone marrow). We assumed that the insidious clinical presentation could be due to the anti-bacilar activity of quinolones prescribed for several times prior to hospital admission.