1
|
Satchithanantham V, Babiker T, Riding G, Banihani M. A case of mycotic infrarenal abdominal aortic aneurysm after bacillus Calmette-Guérin immunotherapy for bladder cancer and a review of the literature. J Vasc Surg Cases Innov Tech 2023; 9:101213. [PMID: 37388673 PMCID: PMC10300401 DOI: 10.1016/j.jvscit.2023.101213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 04/24/2023] [Indexed: 07/01/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Vinojan Satchithanantham
- Department of Vacular Surgery, Lancashire Teaching Hospitals NHS Foundation Trust, Fulwood, United Kingdom
- Department of Surgery, Faculty of Medicine, University of Jaffna, Jaffna, Srilanka
| | - Thamer Babiker
- Lancashire Teaching Hospitals NHS Foundation Trust, Fulwood, United Kingdom
| | - Graham Riding
- Lancashire Teaching Hospitals NHS Foundation Trust, Fulwood, United Kingdom
| | - Mohamed Banihani
- Lancashire Teaching Hospitals NHS Foundation Trust, Fulwood, United Kingdom
| |
Collapse
|
2
|
Nishizawa M, Kudo T, Kijima T, Fujii Y. Failed endovascular abdominal aortic aneurysm repair due to Mycobacterium bovis infection following intravesical bacillus Calmette-Guérin therapy. J Vasc Surg Cases Innov Tech 2022; 8:807-812. [PMID: 36507086 PMCID: PMC9729924 DOI: 10.1016/j.jvscit.2022.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 10/26/2022] [Indexed: 11/09/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Masato Nishizawa
- Department of Vascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshifumi Kudo
- Department of Vascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan,Correspondence: Toshifumi Kudo, MD, PhD, Department of Vascular Surgery, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, Japan 113-8519
| | - Toshiki Kijima
- Department of Urology, Dokkyo Medical University, Tokyo, Japan
| | - Yasuhisa Fujii
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| |
Collapse
|
3
|
Tehrani N, Will S, Halandras P. Endovascular repair of a Bacillus Calmette-Guerin mycotic aortic aneurysm. J Vasc Surg Cases Innov Tech 2022; 8:570-573. [PMID: 36248393 PMCID: PMC9556591 DOI: 10.1016/j.jvscit.2022.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/19/2022] [Indexed: 11/23/2022] Open
Abstract
Bacillus Calmette-Guérin (BCG) is an attenuated form of Mycobacterium bovis used for intravesical treatment of bladder carcinoma. Aortic infection has been rare. In the present report, we have described the case of a patient with an infrarenal mycotic aortic pseudoaneurysm and para-aortic abscess after intravesical bacillus Calmette-Guérin and cystectomy. Sampling of the abscess demonstrated acid-fast bacilli. Given the hostile anatomy of the abdomen, he was offered endovascular aortic repair. A thoracic endograft was used to cover the lesion. The patient was discharged on postoperative day 2 without incident. He was seen at 1 and 6 months with resolution of his pseudoaneurysm found on the imaging studies. The technique shows promise for stabilizing such lesions with close surveillance.
Collapse
|
4
|
Yi S, Sheng L, Li W. Therapeutic effectiveness of tuberculous aneurysm and risk factors for mortality: a systematic review. Gen Thorac Cardiovasc Surg 2022; 70:515-525. [PMID: 35378674 PMCID: PMC9135858 DOI: 10.1007/s11748-022-01811-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 03/13/2022] [Indexed: 12/17/2022]
Abstract
OBJECTIVE This study aimed to determine the therapeutic effectiveness of tuberculous aortic aneurysms (TBAAs) and the risk factors for mortality. METHODS We reviewed all case reports of TBAAs treated with open surgery or endovascular aneurysm repair (EVAR) from online database in 1996-2021. Only thoracic and abdominal aortic aneurysms were included. RESULTS Eighty cases of open surgery and 42 cases of EVAR were included. The 2-year mortality and perioperative mortality rates of open surgery were 11.3% and 10.0%, respectively. Emergent open surgery had a significantly higher mortality (25.0%) than non-emergent open surgery (6.7%). In the EVAR group, 2-year mortality, perioperative mortality, and TBAA-related mortality were 16.7%, 4.8%, and 10.0%, respectively. Patients with typical tuberculosis (TB) symptoms before EVAR had a significantly higher TBAA-related mortality (35.0%) than patients with no typical TB symptoms before EVAR (0%). In the open surgery group, the rate of TB recurrence (2.7% vs 2.4%) and aneurysm recurrence (8.1% vs 7.3%) were quite close between preoperative anti-TB-treated and postoperative anti-TB-treated cases. However, in the EVAR group, TB recurrence (8.7% vs 0%) and aneurysm recurrence (12.5% vs 6.25%) were more common in postoperative anti-TB-treated cases. CONCLUSION Open surgery was accompanied by higher perioperative mortality, whereas EVAR was followed with higher TBAA-related mortality. Emergent surgical choices of open surgery may be associated with high perioperative mortality. Typical TB symptoms before EVAR are a significant risk factor for mortality after EVAR. Early anti-TB treatment should be administered if EVAR is the surgical option.
Collapse
Affiliation(s)
- Shengwu Yi
- Zhejiang Hospital of Chinese Medicine, No. 54 Youdian Road, Hangzhou, Zhejiang, People's Republic of China
| | - Lingjie Sheng
- College of Health Science, Wuhan Sports University, No. 461 Luoyu Road, Wuhan, Hubei, People's Republic of China
| | - Wei Li
- Zhejiang Hospital of Chinese Medicine, No. 54 Youdian Road, Hangzhou, Zhejiang, People's Republic of China.
| |
Collapse
|
5
|
Palmier M, Monnot A, Tenière T, Cohen Q, Plissonnier D. Mycotic arterial aneurysm secondary to BCG intravesical instillation: A review. JOURNAL DE MEDECINE VASCULAIRE 2022; 47:94-105. [PMID: 35691669 DOI: 10.1016/j.jdmv.2022.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
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.
Collapse
Affiliation(s)
- M Palmier
- Department of vascular surgery, Rouen university hospital, 1, rue de Germont, 76031 Rouen cedex, France.
| | - A Monnot
- Department of vascular surgery, Rouen university hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - T Tenière
- Department of vascular surgery, Rouen university hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - Q Cohen
- Department of vascular surgery, Rouen university hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - D Plissonnier
- Department of vascular surgery, Rouen university hospital, 1, rue de Germont, 76031 Rouen cedex, France
| |
Collapse
|
6
|
Systematic review of case reports of Bacillus Calmette-Guerin (BCG) vascular infections. Ann Vasc Surg 2022; 83:369-377. [DOI: 10.1016/j.avsg.2022.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 01/16/2022] [Accepted: 01/19/2022] [Indexed: 12/24/2022]
|
7
|
Liechty AE, Pacifico A, Brant-Zawadzki P. Successful endovascular treatment of abdominal aortic rupture secondary to bacillus Calmette-Guérin vaccine. J Vasc Surg Cases Innov Tech 2022; 8:19-22. [PMID: 35024524 PMCID: PMC8731694 DOI: 10.1016/j.jvscit.2021.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 11/08/2021] [Indexed: 11/30/2022] Open
Abstract
Bacillus Calmette-Guérin (BCG) vaccine has been successfully used to treat bladder cancer. However, sporadic cases of mycotic arterial aneurysms have been reported. These patients typically develop a Mycobacterium bovis infection of an existing aneurysm or graft. In the present report, we have described the case of a patient with a ruptured nonaneurysmal abdominal aorta years after intravesicular BCG therapy. Emergent aortic endograft repair was successful. After subsequent evaluation confirmed M. bovis infection, the patient was treated with a prolonged course of antimycobacterial therapy. Vascular surgeons should maintain suspicion for atypical aortic ruptures in patients with exposure to intravesicular BCG therapy.
Collapse
|
8
|
Flynn D, Ogi A, Subedi S, Langton J, Choong K, O'Donnell J. Mycotic aortic aneurysm formation following intravesical BCG treatment for transitional cell carcinoma of the bladder. BMJ Case Rep 2021; 14:e246389. [PMID: 34815228 PMCID: PMC8611418 DOI: 10.1136/bcr-2021-246389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2021] [Indexed: 11/04/2022] Open
Abstract
Mycotic aneurysms are rare and if left untreated, can have devastating outcomes. In this case, a 72-year-old man presented to hospital with fevers, night sweats and abdominal pain. A CT scan revealed the development an infrarenal pseudoaneurysm over the course of 8 weeks, increasing from 2.8 cm to a 3.1 cm. The aneurysm was not present on a CT scan performed 6 months earlier. The patient underwent an emergency endovascular repair of the aortic aneurysm (EVAR) and was placed on broad-spectrum antibiotics. Intra-aortic blood cultures aspirated adjacent to the aneurysm and tissue biopsy confirmed tuberculosis bovis as the cause of the mycotic aneurysm. The patient had been treated with intravesical BCG for transitional cell carcinoma of the bladder several months prior. The patient was treated with an extended course of antituberculosis medication. He recovered well and was back to his baseline function within weeks.
Collapse
Affiliation(s)
- David Flynn
- Vascular Surgery Department, Sunshine Coast Hospital and Health Service, Birtinya, Queensland, Australia
| | - Akihiro Ogi
- Infectious Diseases Department, Sunshine Coast Hospital and Health Service, Birtinya, Queensland, Australia
| | - Shradha Subedi
- Infectious Diseases Department, Sunshine Coast Hospital and Health Service, Birtinya, Queensland, Australia
| | - Jonathan Langton
- Interventional Radiology Department, Sunshine Coast Hospital and Health Service, Birtinya, Queensland, Australia
| | - Keat Choong
- Infectious Diseases Department, Sunshine Coast Hospital and Health Service, Birtinya, Queensland, Australia
| | - Jill O'Donnell
- Vascular Surgery Department, Sunshine Coast Hospital and Health Service, Birtinya, Queensland, Australia
| |
Collapse
|
9
|
Buerger M, Kapahnke S, Omran S, Müller V, Hinterseher I, Greiner A, Frese JP. [Aortic Complications Related to Mycobacterium bovis after Intravesical Bacille Calmette-Guérin Therapy - a Systematic Review]. Zentralbl Chir 2021; 146:506-520. [PMID: 34666364 DOI: 10.1055/a-1592-1709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
Collapse
Affiliation(s)
- Matthias Buerger
- Klinik für Gefäßchirurgie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Sebastian Kapahnke
- Klinik für Gefäßchirurgie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Safwan Omran
- Klinik für Gefäßchirurgie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Verena Müller
- Klinik für Gefäßchirurgie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Irene Hinterseher
- Klinik für Gefäßchirurgie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Greiner
- Klinik für Gefäßchirurgie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jan Paul Frese
- Klinik für Gefäßchirurgie, Charité Universitätsmedizin Berlin, Berlin, Germany
| |
Collapse
|
10
|
Patelis N, Nana P, Spanos K, Tasoudis P, Brotis A, Bisdas T, Kouvelos G. The Association of Spondylitis and Aortic Aneurysm Disease. Ann Vasc Surg 2021; 76:555-564. [PMID: 33951524 DOI: 10.1016/j.avsg.2021.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 03/25/2021] [Accepted: 04/03/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The aim of this study is to assess any relation between spondylitis and aortic aneurysmal disease by reviewing the current literature. METHODS A systematic search was undertaken using MEDLINE, EMBASE and CENTRAL databases till May 2019, for articles reporting on patients suffering from spondylitis and aortic aneurysm. RESULTS The most involved aortic segment was infrarenal aorta (56.9%). The lumbar vertebrae were more frequently affected (79.7%). Commonest symptoms were back pain (79.1%), fever (33.7%) and lower limb pain (29.1%). 55.8% of cases were diagnosed using computed tomography. The pathology was attributed to infectious causes in 25.1% of cases. 53.4% of patients were treated only for the aneurysm, 27.9% for both pathologies, while two patients solely for the vertebral disease. Endovascular aneurysm repair was chosen in 12.8% of cases. The 30-day mortality was 8.1% (7/86); mostly from vascular complications. CONCLUSIONS A synchronous spondylitis and aortic aneurysm may share common etiopathology, when an infectious or inflammatory cause is presented. The lumbar vertebrae are more frequently affected. Low quality data do not allow safe conclusion to suggest the best treatment option.
Collapse
Affiliation(s)
- Nikolaos Patelis
- 3rd Department of Vascular Surgery, Athens Medical Center, Marousi, Greece
| | - Petroula Nana
- Department of Vascular Surgery, Larissa University Hospital, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Greece.
| | - Konstantinos Spanos
- Department of Vascular Surgery, Larissa University Hospital, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Panagiotis Tasoudis
- Department of Vascular Surgery, Larissa University Hospital, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Alexandros Brotis
- Neurosurgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Theodosios Bisdas
- 3rd Department of Vascular Surgery, Athens Medical Center, Marousi, Greece
| | - George Kouvelos
- Department of Vascular Surgery, Larissa University Hospital, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Greece
| |
Collapse
|
11
|
Buerger M, Kapahnke S, Omran S, Schomaker M, Rief M, Greiner A, Frese JP. Aortic aneurysm and aortic graft infection related to Mycobacterium bovis after intravesical Bacille Calmette-Guérin therapy-a case series. BMC Surg 2021; 21:138. [PMID: 33731071 PMCID: PMC7972206 DOI: 10.1186/s12893-021-01142-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 03/09/2021] [Indexed: 11/10/2022] Open
Abstract
Background So called “mycotic” aortic aneurysms account for only 0.7 to 1.3% of all aortic aneurysms and are commonly caused by Staphylococcus aureus and Salmonella species. Bacillus Calmette-Guérin (BCG), a live attenuated strain of Mycobacterium bovis, is part of the therapy of non-muscle-invasive bladder cancer (NMIBC). Case presentation We report a case series of three patients with a mycobacterial graft infection related to BCG after surgical treatment of a presumed mycotic aortic aneurysm as an extremely rare complication after NMIBC treatment. All three patients developed aortic aneurysm after BCG instillation and subsequent mycobacterial graft infection. Conclusion Diagnosis requires a high degree of suspicion because of its nonspecific symptoms and imaging. The pathogen is not detected by standard microbiological testing. Treatment includes triple antimycobacterial therapy and radical surgical interventions. Graft preservation may be considered if no anastomosis is involved. Supplementary Information The online version contains supplementary material available at 10.1186/s12893-021-01142-1.
Collapse
Affiliation(s)
- M Buerger
- Department of Vascular and Endovascular Surgery, Charité - Universitätsmedizin Berlin, corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, 12203, Berlin, Germany.
| | - S Kapahnke
- Department of Vascular and Endovascular Surgery, Charité - Universitätsmedizin Berlin, corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - S Omran
- Department of Vascular and Endovascular Surgery, Charité - Universitätsmedizin Berlin, corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - M Schomaker
- Department of Vascular and Endovascular Surgery, Charité - Universitätsmedizin Berlin, corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - M Rief
- Institute of Radiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Luisenstraße 10, 10117, Berlin, Germany
| | - A Greiner
- Department of Vascular and Endovascular Surgery, Charité - Universitätsmedizin Berlin, corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - J P Frese
- Department of Vascular and Endovascular Surgery, Charité - Universitätsmedizin Berlin, corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| |
Collapse
|
12
|
Broekx S, Buelens E. Tuberculous spondylitis following intravesical bcg-instillation in the treatment of transitional cell carcinoma: Case report and systematic review. Clin Neurol Neurosurg 2020; 194:105944. [PMID: 32480296 DOI: 10.1016/j.clineuro.2020.105944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/11/2020] [Accepted: 05/17/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Tuberculous spondylitis (TS), also known as Pott's disease (PD), is a form of tuberculosis in which the vertebral column is affected. Since the first description by Katz et al. in 1992, it became clear that Bacillus Calmette-Guérin (BCG) instillations in the treatment of superficial transitional cell carcinoma (TCC) form a plausible way in which PD is introduced. Nowadays, BCG forms the most effective treatment modality for superficial TCC. The incidence of other than minor complications have been estimated under five per cent. Here we report a case of TS after BCG-instillation in the treatment of TCC. Furthermore, all available literature concerning this topic was gathered into a systematic review. The primary objective was to create an overview of all available literature concerning TS after intravesical BCG-instillations, with an emphasis on the neurosurgical approach of these patients, forming a scaffold at which future case reports can be compared. As a secondary objective, we tried to raise the awareness concerning this very rare complication of intravesical BCG-instillation as a possible cause of low back pain (LBP). PATIENTS AND METHODS We performed a systematic review, in which patients who developed TS after intravesical BCG-therapy in the treatment of TCC, were examined. A total of twenty-three articles (twenty-four cases) obtained from MEDLINE were included. Search terms included: "tuberculous spondylitis", "Pott's disease", "vertebral osteomyelitis", "intravesical", "Bacillus Calmette-Guérin" and "transitional cell carcinoma". Additional studies were identified by checking reference lists. Furthermore, we present a case concerning one of our own patients who consulted our Neurosurgical department with a similar clinical presentation. This systematic review is in conformity with the PRISMA-guidelines. The case report is in accordance with the CARE statement guidelines. RESULTS Results are based on twenty-five cases (twenty-four cases extracted from previous literature and our case report). All included articles are case reports written in English. Publication year and recruitment time varies from 1992 to 2018. Mean age at clinical presentation varies from 35 to 94 years old (mean 74). All patients were male. Surgery was performed in 17 out of 25 cases (68%). A posterior approach was performed in seven cases (41%), zero anterior approaches (0%), a combined approach in five cases (29%) and not specified in five cases (29%). All patients received intravesical BCG-instillation in the treatment of TCC, ranging from one month to twelve years before clinical presentation (mean 26). Radiographic abnormalities were seen in thoracic vertebral segments in thirteen cases (52%), eleven cases in lumbar segments (44%), one at the thoracolumbar transition level (4%) and not in cervical vertebral segments. CONCLUSION Although very rare, TS should be part of the differential diagnosis in patients with LBP, even years after BCG-instillation for TCC. It mostly affects elderly men and involves the thoracolumbar spine through hematogenous spread via Batson's plexus. Antitubercular therapy remains the mainstay in the treatment of TS. A posterior surgical approach, with debridement and stabilization, should be preferred when surgical intervention seems necessary. To our knowledge, this systematic review forms one of the first comprehensive reviews evaluating neurosurgical intervention for PD following intravesical BCG-therapy in the treatment of TCC.
Collapse
Affiliation(s)
- Senne Broekx
- Departement of Neurosurgery, Ziekenhuis Oost-Limburg, 3600 Genk Belgium.
| | - Eveleen Buelens
- Departement of Neurosurgery, Ziekenhuis Oost-Limburg, 3600 Genk Belgium.
| |
Collapse
|
13
|
Ribeiro L, Rajendran S, Stenson K, Loftus I. Rare case of a proximal descending thoracic aorta mycotic aneurysm following intravesical BCG injections for the treatment of bladder cancer. BMJ Case Rep 2019; 12:12/12/e231595. [PMID: 31843771 DOI: 10.1136/bcr-2019-231595] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
A 79-year-old man presented with an enlarging thoracic aneurysm on the background of superficial bladder cancer treated with intravesical bacillus Calmette-Guérin (BCG) injections. Following the injections, he developed deranged liver function tests and hepatomegaly. Liver biopsy revealed granulomatous hepatitis compatible with disseminated mycobacterial infection (BCG-osis) and was treated with anti-tuberculosis agents for 12 months. A surveillance CT scan performed as a follow-up for his bladder cancer in 2018 revealed a saccular thoracic aneurysm at the ligamentum arteriosum, which was metabolically active on positron emission tomography (PET) scan. Given the timeframe from intravesical instillation of BCG and the metabolic activity on PET scan, the lesion was consistent with a mycotic aneurysm secondary to disseminated mycobacterial infection. Following multidisciplinary team discussion, a thoracic endovascular aneurysm repair was performed. The stent grafts were placed distal to the left subclavian artery with good angiographic results and no immediate postoperative complications. He was initiated on long-term antibiotics to cover potential bacterial pathogens including mycobacterium.
Collapse
Affiliation(s)
- Luis Ribeiro
- Vascular Surgery, St George's Hospital, London, UK
| | - Saissan Rajendran
- Vascular Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | | | - Ian Loftus
- Vascular Surgery, St George's Hospital, London, UK
| |
Collapse
|
14
|
Abstract
This article describes the diagnosis and treatment of a patient with lumbar discitis and osteomyelitis caused by Bacillus Calmette-Guérin instillation therapy for treatment of superficial bladder cancer. Treatment of this rare condition consists of antituberculosis microbial therapy and one or more IV antibiotics to cover multidrug-resistant bacteria in the bone.
Collapse
|
15
|
Vudatha V, Ranson M, Blair L, Ahmed AA. Rapid detection of bacille Calmette-Guérin-associated mycotic aortic aneurysm using novel cell-free DNA assay. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2019; 5:143-148. [PMID: 31193416 PMCID: PMC6529677 DOI: 10.1016/j.jvscit.2018.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 11/13/2018] [Indexed: 11/19/2022]
Abstract
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.
Collapse
Affiliation(s)
- Vignesh Vudatha
- Department of Surgery, University of Central Florida College of Medicine, Orlando, Fla
- Correspondence: Vignesh Vudatha, BS, UCF College of Medicine, 6850 Lake Nona Blvd, Orlando, FL 32827
| | - Mark Ranson
- Department of General Surgery, Division of Vascular Surgery, Florida Hospital Orlando, Orlando, Fla
| | | | | |
Collapse
|
16
|
Effects and Complications of Intravesical Instillation of Bacillus Calmette-Guerin Therapy. CURRENT BLADDER DYSFUNCTION REPORTS 2019. [DOI: 10.1007/s11884-019-00506-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
17
|
Cadiou S, Al Tabaa O, Nguyen CD, Faccin M, Guillin R, Revest M, Guggenbuhl P, Houvenagel E, Pertuiset E, Coiffier G. Back pain following instillations of BCG for superficial bladder cancer is not a reactive complication: review of 30 Mycobacterium bovis BCG vertebral osteomyelitis cases. Clin Rheumatol 2019; 38:1773-1783. [PMID: 30868320 DOI: 10.1007/s10067-019-04500-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 02/28/2019] [Accepted: 03/04/2019] [Indexed: 12/19/2022]
Abstract
Mycobacterium bovis Bacillus Calmette-Guérin (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. We made a review of M. bovis BCG vertebral osteomyelitis after instillations for bladder cancer using PubMed search. We added three new French cases. Twenty-seven cases of BCG vertebral osteomyelitis had been reported on PubMed. Of the 30 cases, all were male, averaging 73.4 ± 8.7 years old. Median time between diagnosis and first and last instillation was 22.5 and 14 months respectively. Half of vertebral osteomyelitis was thoracic and lumbar in the other half. Sensitivo-motor 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. 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.
Collapse
Affiliation(s)
- Simon Cadiou
- Department of Rheumatology, Centre Hospitalier Universitaire de Rennes, 16 Boulevard de Bulgarie, 35200, Rennes, France.
| | - Omar Al Tabaa
- Department of Rheumatology, Centre Hospitalier René Dubos, 95301, Pontoise, France
| | - Chi-Duc Nguyen
- Department of Rheumatology, Hôpital St Philibert GHICL, 249 Rue du grand but, 59462, Lomme, France
| | - Marine Faccin
- Department of Rheumatology, Centre Hospitalier Universitaire de Rennes, 35000, Rennes, France
| | - Raphaël Guillin
- Department of Medical Imaging, Centre Hospitalier Universitaire de Rennes, 35000, Rennes, France
| | - Matthieu Revest
- Infectious Diseases and Intensive Care Unit, CHU Univ Rennes, Inserm U 1230, F-35000, Rennes, France
| | - Pascal Guggenbuhl
- Department of Rheumatology, Centre Hospitalier Universitaire de Rennes, 35000, Rennes, France.,CHU Rennes, Univ Rennes, INSERM, Institut NUMECAN (Nutrition Metabolisms and Cancer), F-35000, Rennes, France.,UMR INSERM U 1241, University of Rennes 1, 35000, Rennes, France
| | - Eric Houvenagel
- Department of Rheumatology, Hôpital St Philibert GHICL, 249 Rue du grand but, 59462, Lomme, France
| | - Edouard Pertuiset
- Department of Rheumatology, Centre Hospitalier René Dubos, 95301, Pontoise, France
| | - Guillaume Coiffier
- Department of Rheumatology, Centre Hospitalier Universitaire de Rennes, 35000, Rennes, France.,UMR INSERM U 1241, University of Rennes 1, 35000, Rennes, France
| |
Collapse
|
18
|
Green DB, Kawashima A, Menias CO, Tanaka T, Redelman-Sidi G, Bhalla S, Shah R, King BF. Complications of Intravesical BCG Immunotherapy for Bladder Cancer. Radiographics 2019; 39:80-94. [DOI: 10.1148/rg.2019180014] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
|
19
|
Ruptured Iliac Pseudoaneurysm after Intravesical Bacillus Calmette-Guérin: Urgent Endovascular Treatment. Case Report and Literature Review. Ann Vasc Surg 2018; 53:269.e1-269.e9. [DOI: 10.1016/j.avsg.2018.05.068] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 04/27/2018] [Accepted: 05/01/2018] [Indexed: 12/29/2022]
|
20
|
Kusakabe T, Endo K, Nakamura I, Suzuki H, Nishimura H, Fukushima S, Yamamoto K. Bacille Calmette-Guérin (BCG) spondylitis with adjacent mycotic aortic aneurysm after intravesical BCG therapy: a case report and literature review. BMC Infect Dis 2018; 18:290. [PMID: 29954321 PMCID: PMC6025820 DOI: 10.1186/s12879-018-3205-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 06/22/2018] [Indexed: 11/10/2022] Open
Abstract
Background Although intravesical bacille Calmette-Guérin (BCG) therapy is accepted as an effective treatment for bladder cancer, serious complications may occur in rare cases. To date, only 4 cases have been reported in which the patient developed a combination of mycotic aortic aneurysm and BCG spondylitis. Accurate diagnosis of BCG spondylitis is important because it is an iatrogenic disease, and its treatment is different from usual tuberculous spondylitis. However, distinguishing BCG spondylitis from usual tuberculous spondylitis is very difficult and takes a long time. In this study, we were able to suspect BCG spondylitis at an early stage from the result of the interferon-gamma release assay (IGRA). Case presentation We encountered a case of BCG spondylitis with adjacent mycotic aortic aneurysm after intravesical BCG therapy in a 76-year-old man. We performed a 2-stage operation to obtain spine stabilization and replace the aneurysm with a synthetic graft. We started multidrug therapy with antituberculosis medication, excluding pyrazinamide, because the patient’s history of BCG therapy, negative IGRA, and positive of tuberculosis-polymerase chain reaction (Tb-PCR) suggested that the pathogenic bacteria of the spondylitis was BCG. Eventually the bacterial strain was identified as BCG by PCR-based genomic deletion analysis. Conclusions BCG infection should be considered in patients who have been treated with BCG therapy, even if the treatment was performed several months to several years previously. In the case of a patient with a history of BCG therapy, a positive Tb-PCR result and negative IGRA result probably suggest BCG infections, if the possibility of false-negative IGRA result can be excluded.
Collapse
Affiliation(s)
- Takuya Kusakabe
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
| | - Kenji Endo
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Itaru Nakamura
- Department of Infection Prevention and Control, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Hidekazu Suzuki
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Hirosuke Nishimura
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Shinji Fukushima
- Department of Infection Prevention and Control, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Kengo Yamamoto
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| |
Collapse
|
21
|
Abstract
Acute pathology in the abdominal aorta is associated with significant morbidity and mortality. The most feared complication of abdominal aortic disease is acute rupture in the setting of atherosclerotic abdominal aortic aneurysm. Although frank rupture often is easily diagnosed on CT, other findings such as a hyperattenuating crescent, discontinuous intimal calcium, and draping of the aorta are subtle signs of aneurysm instability. A true aneurysm should be distinguished from a rapidly growing, saccular pseudoaneurysm in the setting of infectious aortitis, as treatment strategy differs. Acute aortic syndrome involving the abdominal aorta, such as dissection and intramural hematoma, often is an extension of thoracic aortic disease, whereas penetrating atherosclerotic ulcers occasionally involve only the abdominal aorta. The goal of treating acute aortic pathology is to repair and prevent rupture, as well as restore and maintain perfusion of the lower extremities, kidneys, and mesentery. However, both open and endovascular repair of the abdominal aorta may become acutely complicated, resulting in compromise of these goals. Examples include aortoenteric fistula, endoleak, anastomotic pseudoaneurysm, graft infection, and thrombosis or kinking of a stent graft resulting in ischemia of the limbs and mesentery.
Collapse
Affiliation(s)
- William Curtis
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd, Campus Box 8131, St. Louis, MO, 63110, USA.
| | - Motoyo Yano
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd, Campus Box 8131, St. Louis, MO, 63110, USA
| |
Collapse
|
22
|
A mycotic aneurysm of the abdominal aorta caused by Mycobacterium bovis after intravesical instillation with bacillus Calmette-Guérin. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2018; 4:122-125. [PMID: 29942898 PMCID: PMC6012987 DOI: 10.1016/j.jvscit.2018.01.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 01/24/2018] [Indexed: 11/24/2022]
Abstract
Intravesical administration of bacillus Calmette-Guérin (BCG), a live attenuated strain of Mycobacterium bovis, plays an important role in adjuvant treatment of superficial bladder cancer. Severe adverse events due to this treatment are rare. Complications of varying character and severity have been described, including rare BCG-related vascular infections. In this writing, we present a case of mycotic abdominal aneurysm caused by M. bovis infection related to prior intravesical BCG instillation.
Collapse
|
23
|
Higashi Y, Nakamura S, Kidani K, Matumoto K, Kawago K, Isobe J, Kanatani J, Kawagishi Y, Sakamaki I, Yamamoto Y. Mycobacterium bovis-induced Aneurysm after Intravesical Bacillus Calmette-Guérin Therapy: A Case Study and Literature Review. Intern Med 2018; 57:429-435. [PMID: 29093394 PMCID: PMC5827329 DOI: 10.2169/internalmedicine.9102-17] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Mycobacterium bovis infection after intravesical Bacillus Calmette-Guérin (BCG) therapy is rare. A 65-year-old Japanese man with history of bladder cancer and intravesical BCG therapy, presented with low-grade fever. An aneurysm with perianeurysmal fluid was suspected and endovascular aortic repair was performed. After 160 days, he developed blood-streaked sputum and computed tomography images revealed that the perianeurysmal fluid area was increasing in size. A multiplex polymerase chain reaction using sputum identified M. bovis. Treatment with anti-tuberculosis drugs reduced the size of the perianeurysmal fluid area. After intravesical BCG therapy, the possibility of M. bovis infection should be considered, thus further investigations are required.
Collapse
Affiliation(s)
- Yoshitsugu Higashi
- Department of Clinical Infectious Diseases, Graduate School of Medicine and Pharmaceutical Sciences for Research, University of Toyama, Japan
| | - Shigeki Nakamura
- Department of Chemotherapy and Mycoses, National Institute of Infectious Diseases, Japan
| | - Kento Kidani
- Department of Clinical Infectious Diseases, Graduate School of Medicine and Pharmaceutical Sciences for Research, University of Toyama, Japan
| | - Kaoru Matumoto
- Department of Clinical Infectious Diseases, Graduate School of Medicine and Pharmaceutical Sciences for Research, University of Toyama, Japan
| | - Koyomi Kawago
- Department of Clinical Infectious Diseases, Graduate School of Medicine and Pharmaceutical Sciences for Research, University of Toyama, Japan
| | - Junko Isobe
- Department of Bacteology, Toyama Institute of Health, Japan
| | | | - Yukio Kawagishi
- Division of Respiratory Medicine, Kurobe City Hospital, Japan
| | - Ippei Sakamaki
- Department of Clinical Infectious Diseases, Graduate School of Medicine and Pharmaceutical Sciences for Research, University of Toyama, Japan
| | - Yoshihiro Yamamoto
- Department of Clinical Infectious Diseases, Graduate School of Medicine and Pharmaceutical Sciences for Research, University of Toyama, Japan
| |
Collapse
|
24
|
Okon E, Stearns J, Durgam AK. Tuberculous Psoas Abscess and Worsening Vascular Aneurysm; All from Bacillus Calmette-Guerin (BCG) Therapy? AMERICAN JOURNAL OF CASE REPORTS 2017; 18:810-812. [PMID: 28720750 PMCID: PMC5528005 DOI: 10.12659/ajcr.903770] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patient: Male, 76 Final Diagnosis: Tuberculous psoas abscess Symptoms: Fever Medication: — Clinical Procedure: — Specialty: Infectious Diseases
Collapse
Affiliation(s)
- Emmanuel Okon
- Department of Infectious Diseases, Marshfield Clinic, Eau Claire, WI, USA.,Department of Infectious Diseases, Sacred Heart Hospital, Eau Claire, WI, USA
| | - Janelle Stearns
- Department of Microbiology, Sacred Heart Hospital, Eau Claire, WI, USA
| | - Arun Kumar Durgam
- Department of Medicine, Marshfield Clinic, Eau Claire, WI, USA.,Department of Medicine, Sacred Heart Hospital, Eau Claire, WI, USA
| |
Collapse
|
25
|
Duvnjak P, Laguna M. Left Anterior Descending Coronary Artery and Multiple Peripheral Mycotic Aneurysms Due to Mycobacterium Bovis Following Intravesical Bacillus Calmette-Guerin Therapy: A Case Report. J Radiol Case Rep 2016; 10:12-27. [PMID: 27761190 DOI: 10.3941/jrcr.v10i8.2697] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The use of live attenuated intravesicular Bacillus Calmette-Guerin (BCG) therapy is a generally accepted safe and effective method for the treatment of superficial transitional cell carcinoma (TCC) of the bladder. Although rare, < 5% of patient's treated with intravesicular BCG therapy may develop potentially serious complications, including localized infections to the genitourinary tract, mycotic aneurysms and osteomyelitis. We present here a case of a 63-year-old male who developed left coronary and multiple peripheral M. Bovis mycotic aneurysms as a late complication of intravesicular BCG therapy for superficial bladder cancer. The patient initially presented with acute onset pain and swelling in the left knee > 2 years following initial therapy, and initial workup revealed a ruptured saccular aneurysm of the left popliteal artery as well as incidental bilateral common femoral artery aneurysms. Following endovascular treatment and additional workup, the patient was discovered to have additional aneurysms in the right popliteal artery and left anterior descending artery (LAD). Surgical pathology and bacterial cultures obtained from the excised femoral aneurysms and surgical groin wounds were positive for Mycobacterium Bovis, and the patient was initiated on a nine-month antimycobacterial course of isoniazid, rifampin and ethambutol. Including the present case, there has been a total of 32 reported cases of mycotic aneurysms as a complication from intravesicular BCG therapy, which we will review here. The majority of reported cases involve the abdominal aorta; however, this represents the first known reported case of a coronary aneurysm.
Collapse
Affiliation(s)
- Petar Duvnjak
- Department of Radiology, Medical College of Wisconsin Affiliated Hospitals, Milwaukee, USA
| | - Mario Laguna
- Department of Radiology, Medical College of Wisconsin Affiliated Hospitals, Milwaukee, USA; Department of Radiology, VA Zablocki hospital, Milwaukee, USA
| |
Collapse
|
26
|
Mackel CE, Burke SM, Huhta T, Riesenburger R, Weller SJ. Mycobacterial Osteomyelitis of the Spine Following Intravesical BCG Therapy for Bladder Cancer. Cureus 2016; 8:e545. [PMID: 27158574 PMCID: PMC4846392 DOI: 10.7759/cureus.545] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 03/26/2016] [Indexed: 12/19/2022] Open
Abstract
Osteomyelitis is an infection of the bone that can involve the vertebral column. A rare cause of vertebral osteomyelitis is Mycobacterium bovis after intravesical Bacillus Calmette-Guerin (BCG) therapy for transitional cell carcinoma of the bladder. In this report, we describe the case of a 64-year-old male presenting with constitutional symptoms, progressive thoracic kyphosis, and intractable T11 and T12 radiculopathies over the proceeding six months. A CT scan revealed erosive, lytic changes of the T12 and L1 vertebrae with compression of the T12 vertebra. An MRI demonstrated T11-12 osteomyelitis with intervening discitis and extensive paraspinal enhancement with a corresponding hyperintensity on a short tau inversion recovery (STIR) sequence. A needle aspiration grew out Mycobacterial tuberculosis complex that was pansensitive to all antimicrobial agent therapies, except pyrazinamide on culture, a finding consistent with an M. bovis infection. The patient's infection and neurologic compromise resolved after transthoracic T11-12 vertebrectomies with decompression of the spinal cord and nerve roots as well as T10-L1 instrumented fusion and protracted antimicrobial therapy. The epidemiology and natural history of M. bovis osteomyelitis are reviewed and the authors emphasize a mechanism of vertebral inoculation to explain the predilection of M. bovis osteomyelitis in males after intravesical BCG therapy.
Collapse
Affiliation(s)
- Charles E Mackel
- Department of Neurosurgery, Tufts University School of Medicine/Tufts Medical Center
| | - Shane M Burke
- Department of Neurosurgery, Tufts University School of Medicine/Tufts Medical Center
| | - Taylor Huhta
- Department of Neurosurgery, Tufts University School of Medicine/Tufts Medical Center
| | - Ron Riesenburger
- Department of Neurosurgery, Tufts University School of Medicine/Tufts Medical Center
| | - Simcha J Weller
- Department of Neurosurgery, Tufts University School of Medicine/Tufts Medical Center
| |
Collapse
|
27
|
A thoracic tuberculous spondylodisctis after intravesical BCG immunotherapy of bladder cancer - Case report and literature review. Neurol Neurochir Pol 2015; 49:460-6. [PMID: 26652884 DOI: 10.1016/j.pjnns.2015.09.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 09/07/2015] [Accepted: 09/09/2015] [Indexed: 11/24/2022]
Abstract
We report a rare case of tuberculosis of the thoracic spine caused by Mycobacterium bovis infection as a complication of BCG (Bacillus Calmette-Guérin) intravesical immunotherapy, which is a well known and acknowledged treatment of superficial bladder cancers applied since 1976. Although this therapy is broadly used in urology and considered to be safe and well tolerated, one should be aware of the potential local and systemic side effects as in the case of our patient, who developed tuberculous spondylodiscitis after intravesical BCG therapy.
Collapse
|
28
|
Leo E, Molinari ALC, Rossi G, Ferrari SA, Terzi A, Lorenzi G. Mycotic abdominal aortic aneurysm after adjuvant therapy with bacillus Calmette-Guérin in patients with urothelial bladder cancer: a rare but misinterpreted complication. Ann Vasc Surg 2015; 29:1318.e1-6. [PMID: 26115610 DOI: 10.1016/j.avsg.2015.01.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Revised: 01/18/2015] [Accepted: 01/31/2015] [Indexed: 11/30/2022]
Abstract
Bacillus Calmette-Guérin (BCG) therapy is often associated with side effects. The most feared is disseminated sepsis that may occur rarely with the development of mycotic aortic aneurysms. Twenty cases of patients treated with intravesical BCG complicated by mycotic abdominal aortic aneurysm have been reported in the literature, including 2 cases of the present study. Delayed vascular work-up represents a critical aspect. Mycotic aneurysms evidence a rapid progression. Primary care physicians and urologists should be sensitized to recognize unspecified symptoms such as potential clinical manifestations of a mycotic abdominal aortic aneurysm, even several months or years after BCG therapy.
Collapse
Affiliation(s)
- Enrico Leo
- Division of Vascular Surgery, Department of Cardiovascular Diseases, A. Manzoni Hospital, Lecco, Italy.
| | - Alessandro L C Molinari
- Division of Vascular Surgery, Department of Cardiovascular Diseases, A. Manzoni Hospital, Lecco, Italy
| | - Giovanni Rossi
- Division of Vascular Surgery, Department of Cardiovascular Diseases, A. Manzoni Hospital, Lecco, Italy
| | - Stefano A Ferrari
- Division of Vascular Surgery, Department of Cardiovascular Diseases, A. Manzoni Hospital, Lecco, Italy
| | - Angelo Terzi
- Division of Vascular Surgery, Department of Cardiovascular Diseases, A. Manzoni Hospital, Lecco, Italy
| | - Giovanni Lorenzi
- Division of Vascular Surgery, Department of Cardiovascular Diseases, A. Manzoni Hospital, Lecco, Italy
| |
Collapse
|
29
|
Davis FM, Miller DJ, Newton D, Arya S, Escobar GA. Successful treatment of a mycotic multifocal thoracoabdominal aortic aneurysm as a late sequelae of intravesical bacillus Calmette-Guerin therapy: case report and literature review. Ann Vasc Surg 2015; 29:840.e9-13. [PMID: 25736202 DOI: 10.1016/j.avsg.2014.12.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 11/26/2014] [Accepted: 12/22/2014] [Indexed: 11/17/2022]
Abstract
Bacillus Calmette-Guerin (BCG) is a live, attenuated strain of Mycobacterium bovis commonly used for the treatment of superficial bladder carcinoma. Intravesical BCG is well tolerated despite side effects that range from hematuria to sepsis syndrome. A very rare complication is vascular infection developing a mycotic BCG aneurysm, especially in the thoracoabdominal aorta (TAAA). These are challenging to diagnose because of their scarcity, nontraditional culture media, slow growth, and are often lethal. We report the first successful repair of a symptomatic, multifocal TAAA secondary to M bovis manifesting 17 months after intravesical BCG therapy and review the literature.
Collapse
Affiliation(s)
- Frank M Davis
- Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, MI
| | - David J Miller
- Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, MI
| | - Duane Newton
- Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, MI
| | - Shipra Arya
- Division of Vascular Surgery and Endovascular Therapy, Emory University, Atlanta, GA
| | - Guillermo A Escobar
- Division of Vascular Surgery, University of Arkansas for Medical Sciences, Little Rock, AR.
| |
Collapse
|
30
|
Pérez-Jacoiste Asín MA, Fernández-Ruiz M, López-Medrano F, Lumbreras C, Tejido Á, San Juan R, Arrebola-Pajares A, Lizasoain M, Prieto S, Aguado JM. Bacillus Calmette-Guérin (BCG) infection following intravesical BCG administration as adjunctive therapy for bladder cancer: incidence, risk factors, and outcome in a single-institution series and review of the literature. Medicine (Baltimore) 2014; 93:236-254. [PMID: 25398060 PMCID: PMC4602419 DOI: 10.1097/md.0000000000000119] [Citation(s) in RCA: 169] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Bacillus Calmette-Guérin (BCG) is the most effective intravesical immunotherapy for superficial bladder cancer. Although generally well tolerated, BCG-related infectious complications may occur following instillation. Much of the current knowledge about this complication comes from single case reports, with heterogeneous diagnostic and therapeutic approaches and no investigation on risk factors for its occurrence. We retrospectively analyzed 256 patients treated with intravesical BCG in our institution during a 6-year period, with a minimum follow-up of 6 months after the last instillation. We also conducted a comprehensive review and pooled analysis of additional cases reported in the literature since 1975. Eleven patients (4.3%) developed systemic BCG infection in our institution, with miliary tuberculosis as the most common form (6 cases). A 3-drug antituberculosis regimen was initiated in all but 1 patient, with a favorable outcome in 9/10 cases. There were no significant differences in the mean number of transurethral resections prior to the first instillation, the time interval between both procedures, the overall mean number of instillations, or the presence of underlying immunosuppression between patients with or without BCG infection. We included 282 patients in the pooled analysis (271 from the literature and 11 from our institution). Disseminated (34.4%), genitourinary (23.4%), and osteomuscular (19.9%) infections were the most common presentations of disease. Specimens for microbiologic diagnosis were obtained in 87.2% of cases, and the diagnostic performances for acid-fast staining, conventional culture, and polymerase chain reaction (PCR)-based assays were 25.3%, 40.9%, and 41.8%, respectively. Most patients (82.5%) received antituberculosis therapy for a median of 6.0 (interquartile range: 4.0-9.0) months. Patients with disseminated infection more commonly received antituberculosis therapy and adjuvant corticosteroids, whereas those with reactive arthritis were frequently treated only with nonsteroidal antiinflammatory drugs (p < 0.001 for all comparisons). Attributable mortality was higher for patients aged ≥65 years (7.4% vs 2.1%; p = 0.091) and those with disseminated infection (9.9% vs 3.0%; p = 0.040) and vascular involvement (16.7% vs 4.6%; p = 0.064). The scheduled BCG regimen was resumed in only 2 of 36 patients with available data (5.6%), with an uneventful outcome. In the absence of an apparent predictor of the development of disseminated BCG infection after intravesical therapy, and considering the protean variety of clinical manifestations, it is essential to keep a high index of suspicion to initiate adequate therapy promptly and to evaluate carefully the risk-benefit balance of resuming intravesical BCG immunotherapy.
Collapse
Affiliation(s)
- María Asunción Pérez-Jacoiste Asín
- Unit of Infectious Diseases (MAPJA, MFR, FLM, CL, RSJ, ML, JMA), Department of Urology (AT, AAP), and Department of Internal Medicine (SP), Hospital Universitario "12 de Octubre," Instituto de Investigación Hospital "12 de Octubre" (i+12), Madrid, Spain
| | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Newman JR, Clough LA, Merino F. Mycobacterium bovis Osteomyelitis of the Thoracic Spine Mimicking a Metastatic Lytic Lesion in a Patient Exposed to Intravesicular Bacille Calmette-Guérin Treatment. Urol Case Rep 2014; 2:142-4. [PMID: 26839794 PMCID: PMC4735490 DOI: 10.1016/j.eucr.2014.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 04/29/2014] [Indexed: 11/05/2022] Open
Abstract
An 80-year-old man with previous intravesicular bacille Calmette-Guérin therapy developed mass lesions of the lower thoracic spine. Metastatic disease was suspected. The patient underwent a course of radiation; however, biopsy later demonstrated fibrosis and cultures grew Mycobacterium bovis. The patient was treated with a course of isoniazid, rifampin, and ethambutol.
Collapse
Affiliation(s)
- Jessica R Newman
- Division of Infectious Diseases, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Lisa A Clough
- Division of Infectious Diseases, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Fernando Merino
- Division of Infectious Diseases, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| |
Collapse
|
32
|
Holmes BJ, LaRue RW, Black JH, Dionne K, Parrish NM, Melia MT. Mycotic aortic aneurysm due to intravesical BCG immunotherapy: Clinical manifestations and diagnostic challenges. Int J Mycobacteriol 2013; 3:60-5. [PMID: 26786225 DOI: 10.1016/j.ijmyco.2013.11.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 11/20/2013] [Indexed: 10/25/2022] Open
Abstract
A live, attenuated form of Mycobacterium bovis, bacillus Calmette-Guérin (BCG), is commonly used as intravesical immunotherapy for non-invasive urothelial bladder carcinoma. While complications are rare, dissemination can occur. A case of mycotic aortic aneurysm following BCG administration with recovery of Mycobacterium bovis in culture is reported. A review of the published experience with this problem is also presented.
Collapse
Affiliation(s)
- Brittany J Holmes
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Richard W LaRue
- Department of Medicine, Division of Infectious Diseases, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - James H Black
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Kim Dionne
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Nicole M Parrish
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Michael T Melia
- Department of Medicine, Division of Infectious Diseases, The Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| |
Collapse
|
33
|
Abdominal Aortic Aneurysmal and Endovascular Device Infection With Iliopsoas Abscess Caused by Mycobacterium Bovis as a Complication of Intravesical Bacillus Calmette–Guérin Therapy. Ann Vasc Surg 2013; 27:1186.e1-5. [DOI: 10.1016/j.avsg.2012.12.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Revised: 11/30/2012] [Accepted: 12/22/2012] [Indexed: 11/19/2022]
|
34
|
Samadian S, Phillips FM, Deeab D. Mycobacterium bovis vertebral osteomyelitis and discitis with adjacent mycotic abdominal aortic aneurysm caused by intravesical BCG therapy: a case report in an elderly gentleman. Age Ageing 2013; 42:129-31. [PMID: 23151379 DOI: 10.1093/ageing/afs164] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The bacille Calmette-Guérin, a live attenuated form of Mycobacterium bovis, has been used as anti-cancer immunotherapy for superficial bladder cancer since 1976 [ 1]. It is now the mainstay of therapy for this condition, which is partly attributable to the low complication rate; indeed 95% have no significant side effects [ 2]. However, proven disseminated M. bovis infection has been documented, as is the case with our elderly patient.
Collapse
Affiliation(s)
- Samad Samadian
- Care of the Elderly, St Helier Hospital, Wrythe Lane Carshalton SM5 1AA, UK.
| | | | | |
Collapse
|
35
|
Demers V, Pelsser V. "BCGitis": A rare case of tuberculous epididymo-orchitis following intravesical Bacillus Calmette-Guérin therapy. J Radiol Case Rep 2012; 6:16-21. [PMID: 23372864 DOI: 10.3941/jrcr.v6i11.1100] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Tuberculous epididymo-orchitis is a rare complication of intravesical Bacillus Calmette-Guérin (BCG) therapy for urothelial cancer of the bladder. We present such a case, describe its sonographic appearance and review the literature. The difficulties in diagnosing this condition based on imaging alone, given the extensive overlap with the appearance of bacterial epididymo-orchitis, malignant testicular disease and testicular torsion, are discussed. Adequate knowledge of tuberculous epididymo-orchitis is of capital importance in order to ensure a proper diagnosis and treatment.
Collapse
Affiliation(s)
- Virginie Demers
- Department of Diagnostic Radiology, Jewish General Hospital, Montreal, Canada.
| | | |
Collapse
|
36
|
Obaid S, Weil AG, Rahme R, Gendron C, Shedid D. Mycobacterium bovis spondylodiscitis after intravesical Bacillus Calmette-Guérin therapy. Surg Neurol Int 2011; 2:162. [PMID: 22140647 PMCID: PMC3228380 DOI: 10.4103/2152-7806.89879] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Accepted: 09/23/2011] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Intravesical instillations of live-attenuated Bacillus Calmette-Guérin (BCG) are a well-known and effective method for prevention and treatment of bladder carcinoma and carcinoma in situ. Although considered a safe procedure with rare side effects, local and systemic complications may occur. While long bone ostemolyelitis has been well described, very few reports of BCG spondylodiscitis exist in the literature. CASE DESCRIPTION A 67-year-old man developed low back pain, anorexia, and weight loss 11 months after a 6-week course of intravesical BCG instillations for the treatment of bladder carcinoma in situ. Imaging studies revealed L1-L2 spondylodiscitis with epidural and bilateral psoas abscesses. Tissue cultures obtained by percutaneous computed tomography-guided aspiration were positive for Mycobacterium bovis. Despite triple antituberculous therapy (isoniazid, rifampin, and ethambutol), clinical and radiological progression occurred. Therefore, L1 and L2 corpectomies with extensive debridement were performed, followed by 360° anterior-posterior instrumented fusion. After 20 months of follow-up, the patient remains asymptomatic and recurrence-free. CONCLUSION Mycobacterium bovis spondylodiscitis is a rare complication of intravesical BCG therapy. Although medical therapy with antituberculous agents is the first-line treatment, surgical decompression, debridement, and stabilization may be necessary in refractory cases.
Collapse
Affiliation(s)
- Sami Obaid
- Division of Neurosurgery, Hôpital Notre-Dame du CHUM, University of Montreal, Montreal, QC, Canada
| | | | | | | | | |
Collapse
|
37
|
A case of Pott's disease with epidural abscess and probable cerebral tuberculoma following Bacillus Calmette-Guérin therapy for superficial bladder cancer. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2011; 21:e75-8. [PMID: 21358881 DOI: 10.1155/2010/572410] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Intravesical Bacillus Calmette-Guérin (BCG) immunotherapy is an accepted treatment for transitional cell carcinoma of the bladder. Carcinoma in situ of the bladder progresses to invasive muscular disease in approximately 54% of untreated patients, mandating early initiation of therapy once the diagnosis is confirmed. Should BCG treatment fail, an additional course of BCG combined with interferon-alpha, both administered intravesically, is a promising second-line immunotherapy. In greater than 95% of patients, BCG is tolerated without significant morbidity or mortality. However, both early (within three months of the original treatment) and late presentations of systemic infection resulting from intravesical BCG treatment have been described. The present study describes the course of a 75-year-old man with a late presentation of BCG vertebral osteomyelitis, discitis, epidural abscess, bilateral psoas abscesses and probable cerebral tuberculoma, following treatment regimens of intravesical BCG followed by intravesical BCG plus interferon-alpha 2b.
Collapse
|
38
|
Rosevear HM, Lightfoot AJ, Nepple KG, O'Donnell MA. Safety and Efficacy of Intravesical Bacillus Calmette-Guérin Plus Interferon α-2b Therapy for Nonmuscle Invasive Bladder Cancer in Patients With Prosthetic Devices. J Urol 2010; 184:1920-4. [DOI: 10.1016/j.juro.2010.06.149] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2010] [Indexed: 10/19/2022]
|
39
|
Manfredi R, Dentale N, Piergentili B, Pultrone C, Brunocilla E. Tubercular disease caused by Bacillus of Calmette-Guérin as a local adjuvant treatment of relapsing bladder carcinoma. Cancer Biother Radiopharm 2010; 24:621-7. [PMID: 19877893 DOI: 10.1089/cbr.2009.0668] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Two (2) exemplary case reports of respiratory granulomatous infection caused by Bacillus of Calmette-Guérin (BCG), in patients who were repeatedly treated with local, intravesical adjuvant BCG therapy for a relapsing transitional bladder carcinoma, are outlined and discussed on the grounds of the cumbersome diagnostic and differential diagnostic process (especially when a prior tuberculosis and a concurrent chronic obstructive pulmonary disease are of concern), along with an updated literature revision. Only 4 cases of respiratory BCG-itis (pulmonary tuberculosis-like forms) have been reported, to date, to the best of our knowledge (2 of them following the bladder instillation of BCG). One (1) episode of ours represents the first described case with a dual, concomitant granulomatous localization of BCG-itis, also involving the genitourinary tract.
Collapse
Affiliation(s)
- Roberto Manfredi
- Department of Internal Medicine, Aging, and Nephrologic Diseases, Division of Infectious Diseases, Alma Mater Studiorum University of Bologna, S. Orsola-Malpighi Hospital, I-40138 Bologna, Italy.
| | | | | | | | | |
Collapse
|
40
|
Coscas R, Arlet JB, Belhomme D, Fabiani JN, Pouchot J. Multiple mycotic aneurysms due to Mycobacterium bovis after intravesical bacillus Calmette-Guérin therapy. J Vasc Surg 2009; 50:1185-90. [DOI: 10.1016/j.jvs.2009.06.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2009] [Revised: 06/01/2009] [Accepted: 06/02/2009] [Indexed: 11/29/2022]
|
41
|
Steichen O. Aortic tuberculous pseudoaneurysm. Spine J 2007; 7:629. [PMID: 17662664 DOI: 10.1016/j.spinee.2007.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2007] [Accepted: 05/10/2007] [Indexed: 02/03/2023]
|
42
|
Segal A, Krauss ES. Infected total hip arthroplasty after intravesical bacillus Calmette-Guérin therapy. J Arthroplasty 2007; 22:759-62. [PMID: 17689788 DOI: 10.1016/j.arth.2006.07.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2006] [Accepted: 07/31/2006] [Indexed: 02/01/2023] Open
Abstract
An infected total hip arthroplasty remains one of the most challenging problems faced by orthopedic surgeons. We present the case of a 76-year-old man with an unusual infected total hip arthroplasty. Four years before presenting to our service, the patient was treated for vesical transitional cell carcinoma with intravesical administration of bacille Calmette-Guérin. The patient presented with groin pain, radiographic loosening of the hip implant, and elevated erythrocyte sedimentation rate and C-reactive protein. He underwent irrigation and debridement of the hip with removal of components. Cultures isolated bacille Calmette-Guérin necessitating treatment with antituberculosis chemotherapy. Bone cultures obtained under computed tomography guidance were negative, and reimplantation surgery was performed with a successful outcome. Pathway of infection spread, diagnosis, and treatment of this rare infection are discussed with review of the literature.
Collapse
Affiliation(s)
- Ayal Segal
- Department of Orthopedic Surgery, Total Joint Replacement Program, North Shore-Long Island Jewish Health System, Glen Cove Hospital, Glen Cove, New York, USA
| | | |
Collapse
|
43
|
Harding GEJ, Lawlor DK. Ruptured mycotic abdominal aortic aneurysm secondary to Mycobacterium bovis after intravesical treatment with bacillus Calmette-Guérin. J Vasc Surg 2007; 46:131-4. [PMID: 17606130 DOI: 10.1016/j.jvs.2007.01.054] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2006] [Accepted: 01/20/2007] [Indexed: 11/26/2022]
Abstract
Bacillus Calmette-Guérin (BCG) is a live attenuated strain of Mycobacterium bovis that has proven effective in the treatment of early-stage bladder cancer. Although intravesical therapy with BCG is generally considered safe, serious complications including hematuria, granulomatous pneumonitis, hepatitis, and life-threatening BCG sepsis are well known. BCG-related vascular infections are rarely reported. We present a case of a ruptured abdominal aortic aneurysm secondary to M bovis infection 2 years after intravesical instillation of BCG and review the related literature.
Collapse
MESH Headings
- Administration, Intravesical
- Aged, 80 and over
- Aneurysm, Infected/microbiology
- Aneurysm, Infected/pathology
- Aneurysm, Infected/therapy
- Antineoplastic Agents/administration & dosage
- Antineoplastic Agents/adverse effects
- Antitubercular Agents/therapeutic use
- Aortic Aneurysm, Abdominal/microbiology
- Aortic Aneurysm, Abdominal/pathology
- Aortic Aneurysm, Abdominal/therapy
- Aortic Rupture/microbiology
- Aortic Rupture/pathology
- Aortic Rupture/therapy
- BCG Vaccine/administration & dosage
- BCG Vaccine/adverse effects
- Carcinoma, Transitional Cell/therapy
- Humans
- Male
- Mycobacterium bovis/isolation & purification
- Tomography, X-Ray Computed
- Treatment Outcome
- Tuberculosis, Cardiovascular/complications
- Tuberculosis, Cardiovascular/diagnosis
- Tuberculosis, Cardiovascular/microbiology
- Tuberculosis, Cardiovascular/therapy
- Urinary Bladder Neoplasms/therapy
- Vaccines, Attenuated/adverse effects
- Vascular Surgical Procedures
Collapse
Affiliation(s)
- Gregory E J Harding
- Division of Vascular Surgery, London Health Sciences Centre and University of Western Ontario, 800 Commissioners Road E., London, Ontario, Canada
| | | |
Collapse
|
44
|
Affiliation(s)
- Jongmin Lee
- Department of Diagnostic Radiology, Kyungpook National University Hospital, Daegu, Korea
| |
Collapse
|
45
|
Miller DV, Oderich GS, Aubry MC, Panneton JM, Edwards WD. Surgical pathology of infected aneurysms of the descending thoracic and abdominal aorta: Clinicopathologic correlations in 29 cases (1976 to 1999). Hum Pathol 2004; 35:1112-20. [PMID: 15343514 DOI: 10.1016/j.humpath.2004.05.013] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Infected aortic aneurysms are uncommon, and only rarely have their surgical pathological features been described. Clinical and histopathologic features were evaluated in patients undergoing surgical repair of infected aneurysms of the descending thoracic or abdominal aorta over a 24-year period. Findings were compared with observations (primarily from autopsy studies) from the previous 25-year period (1950 to 1975) and other more recent reports. Of the 29 patients in our study, 79% were men, 90% had risk factors for atherosclerosis, and 72% had an identifiable risk or source of infection. Fever was present in 76%, and abdominal or back pain was seen in 66%. Among the 20 cases with an identifiable causative organism, staphylococcus accounted for 30%, streptococcus for 20%, salmonella for 20%, Escherichia coli for 15%, and other organisms for 15%. Aneurysms were saccular in 59% and infrarenal in 42%, and had a mean diameter of 5.6 cm. Microscopically, 6 patterns were recognized: acute inflammation superimposed on severe chronic atherosclerosis (55%), atherosclerosis with chronic inflammation (20%), acute inflammation without atherosclerosis (7%), chronic adventitial inflammation (7%), pseudoaneurysm formation (7%), and necrotizing granulomatous inflammation (4%). Special stains for organisms were positive in only 38% of the cases. Pathological findings of this series of surgical specimens spanning the fourth quarter of the twentieth century were not appreciably different from those described in autopsy series from the preceding years, although the causative microorganisms and agents used to treat them, preoperative diagnostic modalities, and surgical approaches have evolved.
Collapse
Affiliation(s)
- Dylan V Miller
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA
| | | | | | | | | |
Collapse
|
46
|
Tuberculous Vasculitis and Mycotic Aneurysms. Tuberculosis (Edinb) 2004. [DOI: 10.1007/978-3-642-18937-1_43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
47
|
Allins AD, Wagner WH, Cossman DV, Gold RN, Hiatt JR. Tuberculous infection of the descending thoracic and abdominal aorta: case report and literature review. Ann Vasc Surg 1999; 13:439-44. [PMID: 10398742 DOI: 10.1007/s100169900280] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We report here a case of infrarenal aortic disruption and aortoduodenal fistula secondary to tuberculous aortitis in a 77-year-old man. From a review of experience with operative management of tuberculous infection of the descending thoracic and abdominal aorta reported in the English-language literature, including the current report, we found that operative repair was attempted in 26 patients with tuberculous aortitis of the abdominal (n = 16), thoracic (n = 8), and thoracoabdominal (n = 2) aorta. Six patients had emergent operations for massive hemoptysis (n = 2), aortoduodenal fistula (n = 2), or abdominal rupture (n = 2), with an associated 30-day mortality of 50%. Elective or semi-elective repair was undertaken in 20 patients, of whom 19 (95%) survived for at least 30 days. On the basis of limited experience with this rare entity, in situ graft replacement is an appropriate treatment of tuberculous aneurysms and pseudoaneurysms of the descending thoracic and abdominal aorta.
Collapse
Affiliation(s)
- A D Allins
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | | | | | | |
Collapse
|
48
|
Seelig MH, Oldenburg WA, Klingler PJ, Blute ML, Pairolero PC. Mycotic vascular infections of large arteries with Mycobacterium bovis after intravesical bacillus Calmette-Guérin therapy: case report. J Vasc Surg 1999; 29:377-81. [PMID: 9950996 DOI: 10.1016/s0741-5214(99)70391-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Disseminated infection after intravesical bacille Calmette-Guérin instillation for bladder cancer is a rare but potential complication. Vascular infection is an additional serious complication but is seldom reported. We present the first report of a small series of patients with vascular infections after intravesical bacille Calmette-Guérin instillation, and we review the related literature.
Collapse
Affiliation(s)
- M H Seelig
- Department of Surgery, Mayo Clinic Jacksonville, and the Departments of Urology and Surgery, Mayo Clinic Rochester, Maine, USA
| | | | | | | | | |
Collapse
|
49
|
Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 29-1998. A 57-year-old man with fever and jaundice after intravesical instillation of bacille Calmette-Guérin for bladder cancer. N Engl J Med 1998; 339:831-7. [PMID: 9750077 DOI: 10.1056/nejm199809173391209] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
50
|
Hotokezaka H, Kitamura A, Matsumoto S, Hanazawa S, Amano S, Yamada T. Internalization of Mycobacterium bovis Bacillus Calmette-Guérin into osteoblast-like MC3T3-E1 cells and bone resorptive responses of the cells against the infection. Scand J Immunol 1998; 47:453-8. [PMID: 9627129 DOI: 10.1046/j.1365-3083.1998.00318.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Mycobacterium bovis BCG (BCG) is a live vaccine used worldwide against tuberculosis. However, it has unfavourable side effects such as osteitis or osteomyelitis, and these sometimes lead to vertebral caries in some patients as a result of bone resorption. Osteoblasts might play a role in the bone resorption caused by BCG infection, because they are central cells in bone metabolism. Cultured osteoblast-like cell lines (MC3T3-E1) derived from C57BL mice susceptible to BCG infection cells were infected with BCG at several doses. Interestingly, internalization of BCG-enveloped phagosome-like membrane in osteoblast-like cells were observed by transmission electron microscopy (TEM). Owing to infection, the proliferation and alkaline phosphatase activity of the osteoblast-like cells were reduced in a dose-dependent manner. On the other hand, interleukin (IL)-6 production was considerably enhanced by infection. These results suggest that BCG infects osteoblasts, suppressing their proliferation and differentiation and inducing bone resorption, which may be related to osteitis/osteomyelitis and bone caries caused by BCG infection.
Collapse
Affiliation(s)
- H Hotokezaka
- Department of Orthodontics, Nagasaki University School of Dentistry, Sakamoto, Japan
| | | | | | | | | | | |
Collapse
|