Transitional cell carcinoma is the sixth most common cancer among men and the 17th most common cancer in women. The treatment methods for the condition range from noninvasive chemotherapy to more invasive procedures like cystectomy and complete transurethral resection of bladder tumor (TURBT) followed by intravesical Bacillus Calmette-Guérin (BCG) therapy (BCG). Intravesical BCG treatment is known to be effective as it is associated with increased survivability and long-term benefits, especially in early-stage, minimally-invasive disease. It is generally considered to be safe, even though some adverse reactions have been described. Vertebral osteomyelitis secondary to intravesical BCG therapy is a rare complication but one that has been reported in the literature. Although our patient had multiple comorbidities, including a previous vertebral compression fracture prior to treatment, complications from intravesical BCG treatment should always be considered in the differential. Further multi-center retrospective studies are needed to better ascertain its true risk given its increasing use as a treatment modality for transitional cell carcinoma.

Introduction: Histoplasmosis is a disease caused by the fungus Histoplasma capsulatum, and is endemic to the Ohio and Mississippi River Valleys. Itprimarily affects the lungs. However, in immunocompromised patients, the disease can disseminateand is often fatal if not treated. The majority of cases occur in AIDS patients not on HAART therapy and with CD4 cell counts less than 150. Other cases of disseminated disease occur in transplant recipients, usually six months to a year post-transplant. In this report, we discuss the case of a renal transplant patient who traveled to and stayed for an extended time in an area nonendemic for Histoplasmosis fungus, and eventually developed disseminated infection. Case: A 74-year old Hispanic Male, originally from the Dominican Republic (DR), received a renal transplant in New York (NY) after renal failure from diabetic nephropathy. He was compliant with immunosuppressive medications. The patient had made frequent travels between his family's farm in rural DR and the US. He developed new worsening shortness of breath over two months, more severe when he was in the DR. He developed respiratory failure, was intubated, and flown to a hospital ICU in the US for further care. Initial chest x-ray (CXR) was concerning for a disseminated pulmonary infection with diffuse interstitial opacities. CT Chest without contrast showed enlarged hilar lymph nodes, with the largest measuring 1.3 cm in size; in addition, extensive bilateral lower lung ground glass opacities were seen. A bronchoscopy was performed, and bronchoalveolar lavage samples revealed Histoplasmosis fungus; a Histoplasmosis urine antigen was positive as well. The patient continued to deteriorate as he developed multi-organ failure from sepsis. Despite aggressive resuscitation antifungal treatment with itraconazole and amphotericin B, the patient expired one week after ICU admission. Discussion: The presence of Histoplasmosis and the patient's travel history brought into question the method of acquisition. He had not traveled to any known endemic areas in the US or abroad. The DR is not known to be endemic for the fungus. Records show the patient and kidney were fungus-free before and just after transplant. It seems he acquired Histoplasmosis after travels to the DR posttransplant, as his presenting symptoms suggest. His case begs the question of testing patients for fungal infections even outside endemic areas prior to starting immunosuppressive medications. Additionally, the issue of avoidance of travel to areas with endemic fungal and other infections should be considered in immunocompromised patients.