Myobacterium bovis peri-prosthetic hip infection with successful prosthesis retention following intravesical BCG therapy for bladder carcinoma

Abstract

Systemic dissemination and peri-prosthetic infection of Mycobacterium bovis (M. bovis) following intravesical Bacillus Calmette-Guerin (BCG) therapy presents a rare but significant complication of treatment for non-muscle invasive bladder carcinoma. We present a patient with Mycobacterium bovis infection of a prosthetic hip nine months following BCG therapy for bladder cancer. The debridement and (implant) prosthesis retention approach in conjunction with anti-tuberculous medication (DAIR) employed in this case, allowed the same prosthesis to be retained. This case report highlights the importance of physician awareness of the possibility BCG peri-prosthetic infections.

The double-edged sword - prosthetic joint infection following BCG treatment for bladder cancer: a case report

“…They generally present months to years after their last BCG instillation with worsening localized pain at the site of their arthroplasties and evidence of local bone lesions on radiograph [12, 14–20]. Only one case had a co-morbid immunosuppressive diagnosis (diabetes) [14], only one had systemic B-symptoms [18], and five had elevated serum measurements of acute phase reactants [13, 15–18]. All cases had microbiological confirmation of M. bovis and received appropriate anti-tuberculous treatment in addition to surgical source control.…”

Mycobacterium bovis infection of total hip arthroplasty after intravesicular Bacillus Calmette-Guérin

“…A review of the literature revealed 9 previously reported cases of prosthetic M. bovis infection associated with intravesical BCG [6], [7], [8], [9], [10], [11], [12], [13], [14] (Table 1). The time from BCG instillation to presentation ranged from 0 to 48 months, with the majority presenting by 2 years.…”

“…All previously reported cases were treated with a minimum of 2 antituberculosis medications, with an average treatment duration of 14 months. Only one case of THA infection was managed with retention of the prosthesis; however, at 27 months, there was a persistent discharging sinus requiring suppressive treatment with clindamycin [10]. Rispler et al.…”

“…Reoperation at 9 months, femoral head replacedIsoniazid and rifampin for 1 year after second revisionFollow-up after 12 months of treatment therapy—no sign of active infectionAitchison et al. 2015 [10]80/maleThird revision THA 11 years prior9Fluid-filled mass in buttock, associated night sweats, anorexia, weight loss, malaise, and fatigueXR: osteolysis around acetabular cup & distal prosthesis with bone loss. Nuclear medicine: increased uptake both componentsESR 55 mm/h, CRP 64.6 mg/LDebridement and washout.…”

“…However, the treatment is not benign, and the use of a live bacterium produces inherent risks including the potential for systemic dissemination of M. bovis and subsequent seeding to artificial heart valves and implanted cardiac defibrillators [4], [5]. There have been isolated reports of infections of hip and knee arthroplasties, usually requiring 1- or 2-stage revision [6], [7], [8], [9], [10], [11], [12], [13], [14]. We present a case of M. bovis infection of a total hip arthroplasty (THA) 5 years after intravesicular BCG treated by debridement, antibiotics, and implant retention (DAIR).…”