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The potentially toxic nature of intravesical BCG is illustrated by two patients who developed profound systemic illness with fever, rash, basal crackles, and bilateral shadowing on the chest radiograph after treatment.Bacillus Calmette-Guerin (BCG) is an attenuated strain of Mycobacterium bovis that has been used in the treatment A 75 year old man was treated with intravesical BCG (120 mg of BCG in 60 ml of saline) for transitional cell carcinoma of the bladder. After his third monthly treatment he presented with a seven day history of cough and fever and increasing dyspnoea for one day. He was febrile and he had bilateral basal inspiratory crackles and palpable purpuric skin lesions 3-4 mm in diameter over the thorax. A full blood count showed mild leucocytosis. Alkaline phosphatase activities were mildly increased. A chest radiograph showed bilateral interstitial infiltrates. Granulomas were seen on transbronchial lung biopsy. Skin biopsy showed erythema multiforme; neither granulomas nor acid fast bacilli were seen. Intensive care was needed because of hypoxaemic respiratory failure five days after admission to hospital. Isoniazid 300 mg daily, rifampin 600 mg daily, and prednisone 60 mg daily were started on the day of his transfer. On the 14th day an open lung biopsy was performed because of increasing hypoxaemia and progressive radiographic infiltrates. Diffuse alveolar damage (acute and organising) and granulomatous inflammation were noted (figure). No acid fast bacilli were seen and cultures were negative for mycobacteria. Viral studies, blood cultures, and serological tests for atypical organisms gave negative results.

The lung relies upon epithelial active transport of Na+ to aid in the clearance of fluid from its air spaces. Because it is unknown whether the rate of active Na+ transport by the distal lung epithelium varies during early postnatal age, we performed studies in young guinea pigs (7 and 30 days after birth). We used a single pass isolated perfused lung model in which a Krebs Ringer bicarbonate solution containing 22Na+, [14C]sucrose, and FITC-dextran was placed into the air spaces of the lungs, and apparent permeability-surface area (PS) products were calculated after determining the changes in lung weight and the concentrations of the isotopes in the vascular effluent. The PS product for 22Na+, but not [14C]sucrose, decreased significantly at both ages when amiloride was infused (final concentration of 10(-4) M). Amiloride also decreased the rate of fluid clearance, as assessed by changes in organ weight, at both ages. Although the absolute rate of amiloride-sensitive 22Na+ transport increased with age, morphometric measurement of the alveolar region demonstrated that the rate of amiloride-sensitive 22Na+ transport per unit alveolar surface area was similar. These data indicate that although the guinea pig lung undergoes significant growth shortly after birth, the rate of amiloride-sensitive active Na+ transport per unit surface area remains constant. Since a component of weight loss was insensitive to amiloride, these in vivo studies suggest that the amiloride-insensitive Na+ transport pathways previously identified in cultured lung epithelium exist in the intact lung.

The lung relies upon epithelial active transport of Na+ to aid in the clearance of fluid from its air spaces. Because it is unknown whether the rate of active Na+ transport by the distal lung epithelium varies during early postnatal age, we performed studies in young guinea pigs (7 and 30 days after birth). We used a single pass isolated perfused lung model in which a Krebs Ringer bicarbonate solution containing 22Na+, [14C]sucrose, and FITC-dextran was placed into the air spaces of the lungs, and apparent permeability-surface area (PS) products were calculated after determining the changes in lung weight and the concentrations of the isotopes in the vascular effluent. The PS product for 22Na+, but not [14C]sucrose, decreased significantly at both ages when amiloride was infused (final concentration of 10(-4) M). Amiloride also decreased the rate of fluid clearance, as assessed by changes in organ weight, at both ages. Although the absolute rate of amiloride-sensitive 22Na+ transport increased with age, morphometric measurement of the alveolar region demonstrated that the rate of amiloride-sensitive 22Na+ transport per unit alveolar surface area was similar. These data indicate that although the guinea pig lung undergoes significant growth shortly after birth, the rate of amiloride-sensitive active Na+ transport per unit surface area remains constant. Since a component of weight loss was insensitive to amiloride, these in vivo studies suggest that the amiloride-insensitive Na+ transport pathways previously identified in cultured lung epithelium exist in the intact lung.

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