Miliary tuberculosis induced by intravesical Bacille Calmette-Guerin (BCG) immunotherapy for bladder carcinoma: A case report

We report an unusual case of an 82-year-old male patient with superficial bladder tumour who was treated with transurethral resection of bladder tumour followed by intravesical therapy with Bacille Calmette-Guerin (BCG). Two months after the last dose of BCG he presented with fever, weight loss and lethargy. Computed Tomography of the chest, abdomen and pelvis was performed to exclude metastatic disease. However, the lung appearances were suggestive of pulmonary tuberculosis and sputum culture subsequently grew Mycobacterium bovis, the same strain of mycobacterium as used in the intravesical BCG immunotherapy. Antituberculous chemotherapy was commenced but unfortunately the patient developed deep vein thrombosis and died within a few days of starting antituberculous chemotherapy. Multiple studies have demonstrated that transurethral resection of the transitional cell carcinoma followed by intravesical instillation of BCG in the treatment of and prophylaxis against recurrent stages Ta and T1 tumours and carcinoma in situ significantly reduces recurrence and prolongs disease free survival. Toxic side effects of BCG immunotherapy can be divided into local and systemic. Local side effects include cystitis, haematuria, bladder contracture, prostatitis, epididymo-orchitis, ureteral obstruction and renal abscess. Systemic side effects include fever, malaise, pneumonitis, hepatitis, rash, arthralgia, cytopenia and sepsis. The combination of miliary tuberculosis diagnosed on CT and confirmed by sputum culture in such a patient is very unusual. As in other similar cases, Maximum Intensity Projection (MIP) manipulation of the Computed Tomography images helped in the detection of the abnormalities.