Tuberculous Psoas Abscess and Worsening Vascular Aneurysm; All from Bacillus Calmette-Guerin (BCG) Therapy?

BCGitis with aortoiliac aneurysm involvement: Report of two cases and review of the literature

BCGitis is a rare complication after intravesical administration of Bacillus Calmette-Guérin for high-grade superficial bladder cancer and carcinoma in situ. May cause vascular involvement. We present 2 cases and a review of the literature of the case reports pubished on the 10 years prior to April of 2022, when this proyect was finished, which described a case of aortoiliac mycotic aneurysm after receiving this treatment. Of the 51 cases included (49 revised and 2 original), 100% were men, 82% were older than 65 years. The median latency period was 15 months (IQR 18). The most frequent location was the abdominal aorta, rupture occurred in 45,1% of patients. The most frequent symptom was abdominal or lumbar pain (61%), followed by general syndrome (49%). In 39,2% cases, it was associated with retroperitoneal abscesess. Attributable mortality was 13,6%. BCGitis should be included in the differential diagnosis in patients who have received BCG therapy and present vascular involvement, even years after being treated.

A case of mycotic infrarenal abdominal aortic aneurysm after bacillus Calmette-Guérin immunotherapy for bladder cancer and a review of the literature

A 69-year-old patient presented with a 9-month history of constitutional symptoms and a 3-week history of increasing abdominal and back pain. He had a history of bacillus Calmette-Guérin immunotherapy for bladder cancer 9 months earlier. An infrarenal mycotic aneurysm was detected by positron emission tomography-computed tomography. His abdominal aorta was reconstructed using a tube graft tailored from a bovine pericardium sheet. We chose this graft because of its acellular nature and reduced risk of postoperative infection. The culture from the aortic wall yielded acid fast bacilli, and he was treated with antituberculosis medication. His postoperative recovery was uneventful, except for chylous ascites.

Failed endovascular abdominal aortic aneurysm repair due to Mycobacterium bovis infection following intravesical bacillus Calmette-Guérin therapy

A mycotic aneurysm after intravesical instillation of bacillus Calmette-Guérin (BCG) for early-stage bladder cancer is a rare, but life-threatening, complication. In the present report, we have described the case of a patient who had undergone endovascular aneurysm repair for a rapidly growing saccular abdominal aortic aneurysm after BCG therapy. Three months after endovascular aneurysm repair, the patient had developed an abscess that required open surgery. Cultures from a blood sample and the abscess revealed Mycobacterium bovis BCG. A mycotic aneurysm due to BCG therapy should be suspected in patients with a history of BCG treatment. Such patients should immediately start antitubercular therapy.

Muscular pseudotumor revealing a mycobacterial granuloma after bacillus Calmette-Guérin therapy

INTRODUCTION

The Bacillus Calmette-Guérin (BCG) is a live attenuated strain of Mycobacterium bovis. Intravesical therapy with BCG has long been proved to be effective in treating early-stage bladder carcinoma.

CASE REPORT

A 81-year-old male patient with former history of BCG instillations for bladder cancer two years ago was admitted in February 2020 to our department for a pulsatile and painful tumefaction of the right thigh that lasted for 6 months, due to a muscular M. bovis granuloma leading to femoral artery erosion. Emergency vascular surgery associated with prolonged antibiotherapy provided full recovery.

DISCUSSION

Late infectious complications of intravesical BCG instillations are classical but rare. Isolated muscular involvement is exceptional.

CONCLUSION

Mycobacterial infection should be carefully screened face to a granuloma presenting as muscular pseudotumor. A history of BCG therapy, even decades earlier, enhances this hypothesis and should lead to enforce microbiological testing, especially molecular test.

Mycotic arterial aneurysm secondary to BCG intravesical instillation: A review

OBJECTIVE

Mycotic aortic aneurysm is a rare and life-threatening pathology. The first case of mycotic aneurysm induced by immunotherapy with bacille Calmette-Guérin for malignancy was published in 1988. The main objective of this review is to characterize this rare pathology.

MATERIALS AND METHODS

Since then, 60 cases of arterial aneurysm following intra vesical BCG instillation have been described in the literature. All cases have been included, and characteristics have been collected retrospectively, with simple statistical analyses of the cases.

RESULTS

We present a brief review from 1988 to 2022 enhancing the contemporary understanding of this arterial infection. Mycotic aneurysm secondary to BCG instillation has a poor prognosis, up to 50% complication and 15% mortality at 1 month, whether managed by open repair or endovascular means.

CONCLUSION

BCG mycotic aneurysm is an extremely serious condition, the diagnosis of which must be considered at an early stage in order to adapt diagnostic and therapeutic strategies.

Clinical Features of Tuberculosis Pseudoaneurysm and Risk Factors for Mortality

OBJECTIVES

The objective of this study was to determine the clinical features of tuberculosis aneurysms and risk factors for mortality.

MATERIALS AND METHOD

We reviewed all case reports of tuberculous aneurysms in the English literature from January 2000 to December 2020. The clinical features and possible risk factors for mortality were recorded and analyzed.

RESULT

In total, 174 cases of tuberculosis aneurysms were identified. The morbidity of men was more than twice that of women. Male patients (51.47±20.67 years) were older than female patients (39.52±20.23 years), p<0.05. The rupture rate of women (69.2%) was higher than that of men (48.8%). TB-induced aneurysms often spontaneously ruptured 1.41-3.01 months after the onset of TB symptoms without any treatment, and Bacillus Calmette-Guerin (BCG)-induced aneurysms often spontaneously ruptured 10.51-26.49 months after BCG administration. The morbidity of large artery aneurysms was nearly twice that of middle artery aneurysms. However, middle artery aneurysms were more likely to rupture (75.4%) than large artery aneurysms (43.5%), p<0.05. The rupture rate of BCG-induced aneurysms (37.0%) was lower than that of TB-induced aneurysms, regardless of whether there was a TB history (56.7%) or not (57.7%). Symptoms of TB occurred in 63.2% of patients, but only 8.6% of patients had both symptoms of TB and aneurysmal mass effects. Pain was the most common atypical clinical manifestation (50.0%). The Cox proportional hazards regression analysis and Kaplan-Meier estimator showed that rupture and no combined therapy were risk factors for mortality.

CONCLUSION

Tuberculosis aneurysms seemingly shared the same demographic characteristics as common aneurysms. The clinical features of TB-induced aneurysms were different from those of BCG-induced aneurysms in terms of the aneurysm loactation and rupture rate. Tuberculosis aneurysms may occur at any site of the cardiovascular system with a preponderance for large arteries. The changeable clinical manifestations were an important index for diagnosis, but focusing only on clinical manifestations may lead to a missed diagnosis. The combination of anti-TB medications and surgery before aneurysm rupture may provide the best prognosis.

[Aortic Complications Related to Mycobacterium bovis after Intravesical Bacille Calmette-Guérin Therapy - a Systematic Review]

BACKGROUND

Aortic complications after intravesical Bacillus Calmette-Guérin (BCG) application are a rare complication of the treatment of non-muscle invasive bladder cancer. The aim of this systematic review was to perform a descriptive analysis of previously published studies and to discuss the particular challenges of diagnosis and treatment of this rare complication.

MATERIAL AND METHODS

A literature search was performed in PubMed (1949-2021) and Web of Science (1900-2021) using the search terms "mycobacterium" OR "bovis" OR "BCG" AND "aorta" OR "aneurysm". In a staged review process, publications with the following inclusion criteria were included in data analysis: original paper, full-text availability in English or German and aortic complication after intravesical BCG instillation. We focused on the analysis of BCG-specific medical history data as well as treatment strategies in relation to patient outcome and the occurrence of graft infections during follow-up.

RESULTS

A total of 60 individual cases were described in 55 published articles. BCG-induced mycotic aortic aneurysms can occur in all segments of the thoracoabdominal aorta, but the infrarenal aortic segment was most commonly affected (65% of cases). The most common configuration was saccular outpouchings (65%). Concomitant infections in other tissues were typical (65%). Patients with mycotic aneurysm presented with or without consecutive aortic rupture in 28% and 63%, respectively. Diagnosis was based on a combination of pathological and microbiological examinations. A common treatment algorithm was surgical infection treatment (85%) and antitubercular therapy (83%). Performed simultaneously, they resulted in a long-term survival of 81%. Graft infection after initial aortic repair with alloplastic material (n = 40) developed in ten patients (25%) during follow-up.

DISCUSSION

Diagnosis of mycotic aneurysms or vascular complications after intravesical BCG application is exceptionally challenging and a high level of suspicion is required. Diagnosis is based on obtaining sample material of affected regions and the combination of patient's history, clinical presentation and pathological or microbiological examinations. Currently, no consensus guideline for optimal medical treatment options of aortic complications secondary to BCG instillation exists. The combination of surgical treatment and supportive antitubercular therapy seems to achieve the best results. Since the risk of prosthetic infection after the use of alloplastic materials remains high (25%), we strongly suggest evaluating autologous or allogenic aortic replacement during initial aortic repair.

Rapid detection of bacille Calmette-Guérin-associated mycotic aortic aneurysm using novel cell-free DNA assay

Intravesical instillation of bacille Calmette-Guérin (BCG), an attenuated strain of Mycobacterium bovis, is an adjuvant immunotherapy for bladder carcinoma. Typical complications include fever, malaise, and dysuria. However, more severe complications have been reported, including granulomatous pneumonitis, BCG sepsis, and vascular infections. We present a case of an infrarenal abdominal aortic aneurysm complicated by iliopsoas abscess 2 years after BCG treatment and discuss a novel diagnostic tool for mycobacterial strain identification.

Fluorescence in situ hybridization microscopic detection of Bacilli Calmette Guérin mycobacteria in aortic lesions: A case report

RATIONALE

To improve the diagnosis of life-threatening Bacilli Calmette Guérin (BCG) arterial aneurysm in patients treated by intravesical instillation of BCG vaccine as adjunctive therapy for non-muscular bladder carcinoma, is a life-threatening condition. Its diagnosis remains cumbersome.

PATIENT CONCERNS

One patient with a history of intravesical BCG installation presented with aortic aneurysm with routine microscopic examination after Ziehl-Neelsen staining remaining negative.

DIAGNOSES

We used fluorescence in situ hybridization (FISH) to target the Mycobacterium tuberculosis complex rpob gene in a fresh aortic specimen. FISH yielded fluorescent mycobacteria in aortic lesions; mycobacteria were further confirmed as Mycobacterium bovis BCG mycobacteria by polymerase chain reaction (PCR) sequencing.

INTERVENTIONS

The patient benefited from an antituberculous treatment combining rifampicin, isoniazid, and ethambunol.

OUTCOME

A 9-month follow-up indicated a favorable outcome.

LESSONS

This case report teaches that FISH targeting the M tuberculosis complex rpoB gene should be incorporated in the laboratory investigation of aortic aneurysm in patients with a history of bladder carcinoma.