Post-intravesical BCG epididymo-orchitis: Case report and a review of the literature

Testis sparing management of tuberculous epididymitis – Case report

Tuberculous epididymitis is uncommonly encountered and is a very rare complication of Bacillus Calmette-Guérin (BCG) intravesical therapy for the treatment of bladder urothelial cancer. With the increased use of BCG, it is conceivable that practicing urologists will see more patients presenting with this infection. Herein, we describe an unusual presentation of tuberculous epididymitis treated successfully in a conservative fashion with anti-tuberculotic medications and describe current diagnostic, as well as medical and surgical management strategies.

Difficulties in Diagnosing and Treating Disseminated Bacillus Calmette-Guérin (BCG) Infection After Intravesical BCG Therapy in a Patient with Liver Cirrhosis: A Case Report

Patient: Male, 62-year-old

Final Diagnosis: BCGitis

Symptoms: Fever • general fatigue

Medication: —

Clinical Procedure: Bone marrow biopsy • liver biopsy

Specialty: Infectious Diseases • General and Internal Medicine

Spinal Tuberculosis Secondary to Intravesical Bacille Calmette-Guerin Treatment for Bladder Cancer

Intravesical administration of bacille Calmette-Guérin (BCG) is an important component of the gold standard in treating non-muscle invasive bladder cancer (NMIBC). However, complications of this treatment include infections caused by the dissemination of Mycobacterium bovis. We present a case of a 62-year-old man who had been treated with intravesical BCG for bladder cancer and developed an M. bovis infection of his vertebral column. About four months after completing the BCG treatment, he developed an acute onset of severe upper thoracic radicular back pain, with radiation anteriorly to his sternum. Examination revealed the presence of early myelopathy. After other causes were ruled out, he was diagnosed with the infection four months later. He was investigated for the pain, with resulting imaging identifying an erosive ventral epidural mass at the T4-T5 levels causing cord compression. The patient underwent a transthoracic procedure to evacuate the paraspinal mass lesion and obtain a diagnostic biopsy, followed by a posterolateral decompression of the lesion and posterior instrumented stabilization. Pathology resulted in the identification of a granuloma with a single acid-fast bacillus (AFB) from the paraspinal abscess, thus being diagnostic of a mycobacterial granuloma with paraspinal involvement. We subsequently performed an extensive review of current literature, looking at articles on spinal osteomyelitis following intravesical BCG treatment of bladder cancer. We identified 26 documented cases in English literature. We present our case report with a good outcome at 24 months, resolving with appropriate chemotherapy. Additionally, we completed a systematic review of the literature and discuss this infrequent iatrogenic pathology. Our report reveals the good response to targeted therapy in the case of osteomyelitis at other skeletal sites and that practitioners caring for these patients maintain a high degree of suspicion in the workup of these patients. Early identification and treatment can appropriately treat osteomyelitis with good long-term outcomes.

BCG orchitis

Intravesical immunotherapy with Bacillus Calmette-Guerin has been shown to decrease tumor recurrence and progression in urothelial carcinoma of the bladder. Its ubiquitous use is further substantiated by its low rates of complications. Our patient is a 63 year old male with a circuitous medical course who presents with epididymoorchitis and scrotal abscess after his second three week cycle of maintenance BCG prompting scrotal exploration which revealed a non-viable testicle and large scrotal induration with abscess. Pathological analysis and initial cultures were negative for mycobacterium but acid-fast cultures eventually demonstrated mycobacterium three months later.

Tuberculosis epididymo-orchitis following intravesical bacillus Calmette-Guérin immunotherapy

BCG is a well-established treatment for superficial bladder cancer. Although usually well-tolerated, side effects can range from mild cystitis to life-threatening sepsis. Epididymitis is a rare complication of BCG, with only a handful of cases proven to be caused directly by Mycobacterium bovis. We describe one such case, along with radiological findings for this rare complication.

Multiparametric ultrasound findings of tuberculous orchitis following bacillus Calmette-Guérin therapy

Granulomatous bacillus Calmette-Guérin (BCG) infection, both localized and disseminated, as a complication of intravesical therapy for transitional cell carcinoma of the bladder is a recognized but highly unusual phenomenon. We report the case of an 89-year-old gentleman with a history of bladder transitional cell carcinoma and subsequent intravesical BCG instillation of the bladder who presented to his general practitioner with a non-tender lump in his left testis. Histopathologic and microbiological evaluation of the subsequent orchidectomy specimen revealed granuloma formation secondary to BCG infection. The use of bubble contrast agents and elastography in ultrasound to evaluate focal testicular lesions is a relatively novel concept, and we aim to highlight the imaging features of testicular BCG infection using these techniques.

Unusual Case of Testicular Tuberculosis

We describe an unusual case of miliary tuberculous epididymo-orchitis following a BCG-therapy, mimicking malignancy at initial presentation. Genitourinary tuberculosis in a miliary pattern is rare and this case report emphasizes the importance of meticulous analysis of the patient’s clinical history combined with imaging findings in order to ensure an adequate diagnosis and treatment.

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

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.

Disseminated BCG: Complications of Intravesical Bladder Cancer Treatment

Intravesical bacillus Calmette-Guerin (BCG) has been established as an effective treatment of superficial bladder cancer (Parker and Kommu, 2013). However, major side effects, including pneumonitis, sepsis, and even death, may occur in <5% of patients (Gonzalez et al., 2003). Here we present a case of severe disseminated Mycobacterium bovis following intravesical BCG administration. Our patient is a 76-year-old gentleman with newly diagnosed superficial transitional cell carcinoma of the bladder who recently received his first intravesical BCG treatment. He initially presented with hemoptysis and was found to have extensive patchy infiltrates bilaterally. He was treated for pneumonia with antibiotics and then with steroids for hypersensitivity pneumonitis but continued to deteriorate. Due to the temporal proximity of his exposure to BCG, we administered treatment for presumed disseminated BCG infection with rifampin, isoniazid, and ethambutol. Within a 48-hour period, the patient improved dramatically. The reported cases of infection from intravesical BCG illustrate an insidious onset with initial symptoms of low-grade fevers and cystitis but may progress to pneumonitis. If the symptoms persist for more than 7 days or if there is clinical deterioration, RIPE therapy (with rifampin, isoniazid, pyridoxine, and ethambutol) and a fluoroquinolone should be administered for a 6–9-month course along with steroids for 4–6 weeks (Naudžiunas et al., 2012).