DisseminatedMycobacterium bovisinfection post‐kidney transplant following remote intravesicalBCGtherapy for bladder cancer

Abstract

Intravesical Bacillus Camlette-Guérin (BCG) is the treatment of choice for non-muscle invasive bladder cancer, and has been used successfully for over 40 years. A rare and potentially fatal complication of intravesical BCG therapy is BCG-induced sepsis. We report a rare case in which a patient with end-stage renal disease secondary to chronic granulomatous interstitial nephritis underwent remote, pre-transplant intravesical BCG treatment for high-grade non-invasive papillary bladder carcinoma. The patient subsequently received a deceased donor kidney transplant 5 years after BCG therapy, with thymoglobulin induction therapy and standard triple maintenance immunosuppression. Two years post-transplant, he developed BCG-induced sepsis confirmed by cultures from urine, blood, and left native kidney biopsy. He died from disseminated BCG-induced sepsis and failure of his renal allograft. This case highlights the potential adverse reactions associated with intravesical BCG therapy that may occur years after bladder cancer therapy is completed, and should heighten physician awareness for BCG-related infections during pre-transplant assessment and post-transplant care of solid organ transplants recipients.

Clinical Spectrum of Complications Induced by Intravesical Immunotherapy of Bacillus Calmette-Guérin for Bladder Cancer

“…In the largest case series of 45 immunosuppressed patients (12 with solid organ transplants, 23 receiving systemic chemotherapy for unrelated cancer, and 10 on steroids for autoimmune disease) treated with intravesical BCG for bladder cancer, BCG therapy was found well-tolerated, and no BCG sepsis was reported [ 66 ]. In the literature, only one case of disseminated BCG-induced sepsis was reported 7 years after a 6-week induction course of intravesical BCG therapy for high-grade noninvasive papillary urothelial carcinoma and 1.5 years following immunosuppression for a renal transplantation [ 67 ]. Given the fact that this patient's urine and blood mycobacterial culture was positive for the strain of intravesical BCG, the sepsis was most likely caused by organism spreading in the setting of immunosuppression therapy for transplant, rather than systemic hypersensitivity reaction.…”

Preventing tuberculosis in paediatric kidney transplant recipients: is there a role for BCG immunisation pre-transplantation in low tuberculosis incidence countries?

“…One case of disseminated BCG disease has been reported in an adult kidney transplant patient, who had previously received intravesical BCG therapy for uroepithelial carcinoma [50]. Despite the lack of data on the risk of BCG-related complications post solid organ transplant, it is widely accepted that there is a potential risk from any live vaccine used, including BCG [51,52].…”

A Case of Systemic Toxicity Related to Intravesical Bacillus Calmette-Guerin for the Treatment of Bladder Cancer

“…Most of the cases of complications related to BCG treatment have been reported within days to few weeks of intra-vesical administration but there are some cases in which delayed presentation with epididymo-orchitis after 17 years [ 10 ] and disseminated infection in a post-renal transplant patient after five years of initial treatment with BCG [ 11 ] have been reported as well. This points toward the importance of obtaining a detailed history as the very remote history of BCG instillation may get overlooked and the nonspecific presentations and lack of reliable diagnostic means may lead to missing the diagnosis in such cases.…”