Late and Reversible Kidney-Lung Failure after Intra-Bladder BCG Therapy

Abstract

We observed a 76-year-old man who presented “acute kidney-lung failure” 9 months after intravesical Bacillus Calmette-Guerin (BCG) adjuvant treatment for a T1 bladder cancer. He had inflammatory infiltration on chest radiography and required dialysis for acute renal failure. A percutaneous renal biopsy was performed and revealed tubulointerstitial nephritis with a moderate eosinophilic infiltrate without granulomatous lesion. After a few days, an open lung biopsy was also done due to respiratory deterioration. The anatomopathologic specimen demonstrated moderate fibrosis with lympho-neutrophilic infiltration and few aspecific granulomatous lesions without caseous necrosis. Sarcoidosis was suspected and high dose oral methylprednisolone was started. Three weeks later, Mycobacterium bovis was identified by Polymerase Chain Reaction on open lung biopsy. He responded well to steroids and tuberculostatic tri-therapy. After one month of immunosuppressive treatment, renal function was resolved and hemodialysis could be discontinued. Despite the frequent use of adjuvant BCG immunotherapy, systemic complications such as hepatitis, pneumonitis, spondylodiscitis or multiorgan failure are rare (<1%). Hematogenous dissemination which occurs a few weeks after traumatic instillations is usually suspected but not demonstrated because of absence of mycobacterium in histological specimen. Our case differs from those previously reported by the simultaneous presence of acid-fast bacilli highlighted on lung samples. We discuss the pathophysiology of BCG complications, the use of prophylactic or therapeutic treatment and recommend guidelines to prevent such complications.