Mycobacterium bovis vertebral osteomyelitis and discitis with adjacent mycotic abdominal aortic aneurysm caused by intravesical BCG therapy: a case report in an elderly gentleman

Samadian, Samad; Phillips, Frank Murray; Deeab, Dhafer

doi:10.1093/ageing/afs164

Cited by 32 publications

(26 citation statements)

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“…The etiology of the infection is considered to involve hematogenous dissemination from the urinary tract to the vascular endothelium, followed by the formation of a pseudoaneurysm. All of the reported cases have involved men, including the present case, suggesting that the infection could originate from the prostate . However, there have not been any descriptions of prostate‐specific antigen levels or associated prostate conditions in the previous reports, except in one case .…”

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confidence: 71%

“…A total of 27 cases of infectious aortic aneurysms, caused by intravesical BCG instillation, have been previously reported . Most were reported by cardiovascular surgeons, with just three papers from urologists .…”

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confidence: 99%

“…A total of 27 cases of infectious aortic aneurysms, caused by intravesical BCG instillation, have been previously reported. [3][4][5][6][7] Most were reported by cardiovascular surgeons, with just three papers from urologists. [3][4][5] The etiology of the infection is considered to involve hematogenous dissemination from the urinary tract to the vascular endothelium, followed by the formation of a pseudoaneurysm.…”

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confidence: 99%

“…All of the reported cases have involved men, including the present case, suggesting that the infection could originate from the prostate. [3][4][5][6][7] However, there have not been any descriptions of prostate-specific antigen levels or associated prostate conditions in the previous reports, except in one case. 3 The case was diagnosed as granulomatous inflammation of the prostate by transurethral resection 2 years after BCG treatment.…”

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confidence: 99%

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Infectious aortic aneurysms occurring 1 year after bacillus Calmette–Guérin bladder instillation therapy

et al. 2014

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BCG bladder instillation therapy is widely accepted and used, worldwide, for prophylaxis against recurrent non-muscle invasive bladder cancer. Despite its efficacy, various reports have documented the therapy's side-effects.1,2 The most common complications include bladder irritation, fever and gross hematuria; most are considered to be BCG reactions. Systemic infections also occur in some cases that are difficult to diagnose, including local infections not centered in the urinary bladder.We report a patient who presented with an infectious aortic aneurysm 1 year after BCG intravesical instillation therapy for prevention of recurrent non-muscle invasive bladder carcinoma. This complication is extremely rare in the urology domain, but several cases have been reported by cardiovascular surgeons.3-5 The patient, a 72-year-old man with multiple non-muscle invasive bladder carcinomas, was treated using transurethral resection. There was no evidence of thoracic or abdominal aorta aneurysms before BCG instillation (Fig. 1a). Subsequently, BCG (Tokyo 172 strain) bladder instillation therapy (80 mg/instillation, eight instillations) was administered. Before BCG instillation, his laboratory data were normal, including renal and liver functions. He experienced only one night low-grade fever between the first and fifth instillations. Slight bladder irritation symptoms occurred after the seventh instillation. There were no systemic symptoms.One year post-treatment, the patient suffered from constipation, and an abdominal mass was detected by ultrasound. CT showed thoracic (Fig. 1b) and abdominal aortic aneurysms (Fig. 1c). These were diagnosed as infectious aneurysms, because the patient's C-reactive protein levels were slightly increased to 2.44. Other laboratory data were within normal ranges. Furthermore, evidence of prostatitis was not observed in his CT scans, before or after the diagnosis.After diagnosing infectious aneurysms, antibiotics (meropenem and vancomycin) were given, without clinical effect within 2 weeks of the start of treatment. Subsequently, the abdominal aortic aneurysm was replaced with a synthetic graft. A histological examination of the resected aorta showed granulomatous inflammation, and Ziehl-Neelsen staining showed a small number

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Infectious aortic aneurysms occurring 1 year after bacillus Calmette–Guérin bladder instillation therapy

et al. 2014

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“…31 Vertebral osteomyelitis after intravesical BCG instillation for bladder cancer has only been described in 10 prior cases worldwide. 30,[32][33][34][35][36][37][38][39][40] All of the 10 cases described and our patient were men aged 66 to 94 years, with a mean age of 77 years. Diagnosis of osteomyelitis ranged from 2 weeks to 12 years after BCG bladder instillation, with most diagnoses occurring within 2 years of therapy.…”

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confidence: 99%

Mycobacterium bovis Bacillus Calmette-Guérin Vertebral Osteomyelitis After Intravesical Bacillus Calmette-Guérin Used for Bladder Cancer

Vindenes¹,

McGowan²,

Woo-Roderick³

et al. 2015

Infectious Diseases in Clinical Practice

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Background: Bacillus Calmette-Guérin (BCG) is a live attenuated strain of Mycobacterium bovis and has been used for intravesical treatment of superficial bladder cancer since 1976. Systemic complications of intravesical BCG are rare, and vertebral osteomyelitis has only been described in 10 prior cases worldwide.Case: A 64-year-old white man with benign prostatic hyperplasia was diagnosed with transitional cell bladder cancer and underwent transurethral resection of bladder tumor. He received perioperative mitomycin C followed by a 6-week course of intravesical BCG. Recurrent bladder cancer was noted on follow-up cystoscopy and he was started on a second 6-week course of BCG. Before the second intravesical BCG, he developed night sweats and severe progressive back pain with bilateral lower extremity weakness. Magnetic resonance imaging of the spine revealed a T11 to T12 vertebral body destruction with discitis, and biopsy revealed M bovis BCG. He received therapy with isoniazid, rifampin, capreomycin, as well as ethambutol and, later, additional drugs (cycloserine, moxifloxacin) secondary to clinical and radiographic progression of disease. He underwent a T11 to T12 vertebrectomy and continued on isoniazid, rifampin, cycloserine, and moxifloxacin for a total of 12 months postoperatively.Conclusions: Mycobacterium bovis BCG osteomyelitis is a rare complication of intravesical BCG therapy for bladder cancer and may occur as a solitary site of infection. A high degree of suspicion is important in patients with osteomyelitis with a history of transitional cell cancer managed with immunotherapy using BCG instillations.

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Back pain following instillations of BCG for superficial bladder cancer is not a reactive complication: review of 30 Mycobacterium bovis BCG vertebral osteomyelitis cases

et al. 2019

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Introduction: Mycobacterium bovis BCG instillations are used in bladder cancer treatment. Adverse effects can occur. Osteoarticular complications are mainly reactive arthritis, but true infections have been described, such as vertebral osteomyelitis. Methods: We made a review of M. bovis BCG vertebral osteomyelitis after instillations for bladder cancer using PubMed search. We added 3 new French cases. Review: Twenty-seven cases of BCG vertebral osteomyelitis had been reported on PubMed. Of the 30 cases, all were male, averaging 73.4 ± 8.7 year-old. Median time between diagnosis and first and last instillation was 22.5 months and 14 months respectively. Half of vertebral osteomyelitis was thoracic, and lumbar in the other half. Sensitivomotor deficit was present at diagnosis in 42% of cases. Other infectious locations were common, mainly infectious abdominal aortic aneurysms (20%). Rifampicin, ethambutol and isoniazid were the usual therapy. Poor outcomes were reported with 50% of one or more spine surgery. Conclusion: M. bovis BCG vertebral osteomyelitis following bladder instillation for bladder cancer is a rare complication. However, the late onset of back pain after instillations differentiates them from reactive arthritis. Concomitant septic location such as infectious abdominal aortic aneurysms must be known.

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Mycobacterium bovis vertebral osteomyelitis and discitis with adjacent mycotic abdominal aortic aneurysm caused by intravesical BCG therapy: a case report in an elderly gentleman

Cited by 32 publications

References 15 publications

Infectious aortic aneurysms occurring 1 year after bacillus Calmette–Guérin bladder instillation therapy

Infectious aortic aneurysms occurring 1 year after bacillus Calmette–Guérin bladder instillation therapy

Mycobacterium bovis Bacillus Calmette-Guérin Vertebral Osteomyelitis After Intravesical Bacillus Calmette-Guérin Used for Bladder Cancer

Back pain following instillations of BCG for superficial bladder cancer is not a reactive complication: review of 30 Mycobacterium bovis BCG vertebral osteomyelitis cases

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