Nearly Fatal Complications of Cervical Lymphadenitis following BCG Immunotherapy for Superficial Bladder Cancer

Abstract

This report describes the case of a 68-year-old man with bilateral cervical lymphadenitis and chorioretinitis due to bacille Calmette-Guérin (BCG), originating from BCG immunotherapy for treatment of superficial bladder cancer 2 years ago. During antimycobacterial therapy a fistula between the right-sided lymph node and an aneurysm of the carotid artery developed. This led to life-threatening spontaneous bleeding which required vascular graft surgery. Like other known systemic side effects, cervical lymphadenitis may also occur following intravesical BCG immunotherapy, and life-threatening complications cannot be excluded despite adequate medical treatment.

Multiple mycotic aneurysms due to Mycobacterium bovis after intravesical bacillus Calmette-Guérin therapy

“…[6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24] Mean age at diagnosis was 72 years (range, 58-80 years), and aneurysms were diagnosed a mean of 23 months (range, 4-69 months) after BCG therapy. Episodes of fever or fatigue during or immediately after BCG instillations were reported by 11 patients (52%), but were absent in our patient.…”

“…The most frequent clinical symptoms at presentation were abdominal or back pain in 12 (57%), general malaise in 11 (52%), fever in 8 (38%), and pulsatile or painful mass in 4 (19%). The abdominal aorta was involved in 16 patients (76%), but aneurysms of the aortic arch, 9 the femoral arteries, 7,16,19,24 the popliteal artery, 15,20 and the carotid artery 17 were also reported. Similar to our patient, 11 patients (52%) presented with rupture, with histologic finding of arterial wall necrosis in most.…”

“…It was positive in all but one reported case. 8 Other diagnostic tests with lower specificity were also reported and include direct acid-fast bacilli detection, [6][7][8][9][10][11][12]14,15,17,18,[20][21][22][23][24] evidence of typical caseating granulomatous lesions, 6,7,9,13,[17][18][19][20][21][22][23] and PCR 10,18 from various tissue samples.…”

“…In the setting of an infected operative field, revascularization with in situ biologic conduits or extra-anatomic bypasses remains a logical option. Autologous vein grafts 7,17,24 and extra-anatomic 14,23 bypasses were successfully performed. Although never reported, autologous arterial grafts or cryopreserved allografts could be used as alternative conduits.…”

Metachronous Adenoid Cystic Carcinoma in the Peripheral Lung and at Base of the Tongue

“…BCG irrigation after bladder cancer surgery is increasingly employed as a conservative treatment method [18]. BCG lymphadenitis was reported in some cases after BCG irrigation [19]. However, in this case, other treatments for bladder cancer aside from resection were not performed.…”