Epididymo-orchitis and Reiter's disease. Two infrequent complications after intravesical bacillus Calmette-Guérin therapy

Autoimmune disorders caused by intravesical bacillus Calmette-Guerine treatment: A systemic review

Intravesical bacillus Calmette-Guérin (BCG) is a common and highly effective treatment for non-muscle invasive urothelial carcinoma of the urinary bladder. BCG may cause an autoimmune reaction in some patients. One hundred and fifty-eight papers were analyzed, for a total of hundred and thirty patients with reactive arthritis, sixty patients with ocular manifestations and eighteen patients with other rheumatologic diseases. Among 130 subjects with reactive arthritis, an autoimmune symptom occurred after 5 instillations of intravesical BCG (IQR 4-6), which represents 5 weeks in most cases. Fifty-one patients had concurrent ocular involvement. The resolution of symptoms was achieved in a median of 32.5 days (IQR 14-90). Forty-two men and twenty women had ocular manifestations, most commonly conjunctivitis. Patients with HLA-B27 typing had earlier presentation of ocular symptoms related to the number of instillations (4.5 vs 6 [p < 0.05]. Resolution of symptoms was achieved at a median of 128 days (IQR 21-150). Among patients treated with NSAIDs (either with or without steroids), the duration of the disease was significantly shorter in both the articular and the ocular groups (28 vs. 120 [p < 0.05] and 30 vs.105 [p < 0.05], respectively). Other autoimmune manifestations included general autoimmune diseases, such as vasculitis, psoriasis and myasthenia gravis.

The Evaluation of Cases with Ocular Complications due to Bacillus Calmette-Guerin (BCG) Treatment using the Pool Analysis Method

OBJECTIVE

The aim of this study was to investigate cases with ocular complications associated with intravesical BCG therapy in terms of clinical features, demographic features and type of ocular involvement.

METHODS

PubMed database was scanned for relevant publications using the keywords. Thirty-seven publications and 147 reported cases were identified related to the development of ocular complications due to intravesical BCG treatment.

RESULTS

As a result of the analysis performed according to eye involvement, there were 17 cases of conjunctivitis, 7 uveitis, and 5 endophthalmitis. Only 27 (18.3%) cases were of primary ocular involvement and Reiter's syndrome was present in 120 (81.6%) of all cases.

CONCLUSIONS

Most of the side-effects of BCG therapy are minor and of short duration. Although rare, it has been reported that potentially serious ocular complications can develop after treatment. Physicians must keep these facts in mind and be alert to the development of ocular symptoms following BCG therapy.

Bacille calmette-guérin: An ophthalmic perspective

Vaccines such as bacille Calmette-Guérin (BCG) are known for their heterologous effects mediated through a number of mechanisms, including trained immunity constituted by monocyte-macrophage based innate immunity. Other events such as direct hematogenous spread and induction of autoimmunity are also described. There has been a resurgent interest in harnessing some of the benefits of trained immunity in the management of COVID-19, even as several specific vaccines have been approved. We summarize the current knowledge of ocular effects of BCG. Potential effect of granulomatous inflammation on angiotensin converting enzyme activity and accentuation of cytokine storm that may result in undesirable ocular and systemic effects are also discussed.

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

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

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

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.

[Acute arthritis secondary to intravesical bacillus Calmette-Guérin for bladder cancer]

INTRODUCTION

We sought to identify the prevalence, presentation, treatment, and prognosis of acute arthritis secondary to intravesical bacilli Calmette-Guérin (BCG) therapy for bladder cancer.

METHODS

We performed a structured, systematic review of the English language literature pertaining to BCG and reactive arthritis among bladder cancer patients. We extracted data pertaining to prevalence, presentation, management, and prognosis.

RESULTS

We extracted 23 individual case reports and 4 review articles. Thirty-nine patients -31 (80%) male and 8 (20%) female- were described in these publications; we also identified 1 patient from our institution. Although prevalence estimates of reactive arthritis range from 0.5 to 1.0% of all bladder cancer patients receiving BCG, the true prevalence remains unclear. Polyarthritis (68%) and fever (58%) were the most common presenting symptoms. Among patients presenting with joint pain, the knees (41%), ankles (26%), and wrists (19%) were most often affected. The most common time of presentation was immediately following the 4th instillation of a 6-week induction course (25%). Initial therapy in 100% of patients was discontinuation of BCG. Other therapies included nonsteroidal anti-inflammatory drugs (NSAIDs) (25%); steroids (8%); anti-tubercular medications (8%); and combined NSAIDs, steroids, and anti-tubercular medications (20%).

CONCLUSIONS

Reactive arthritis is an infrequent but potentially severe complication of intravesical BCG for bladder cancer that typically presents with polyarthritis and fever during induction. The most common treatments include immediate discontinuation of BCG and systemic anti-inflammatory therapy. Further studies are needed to determine prevalence, pathophysiology, and long-term prognosis.

Vaccination of patients with auto-immune inflammatory rheumatic diseases requires careful benefit-risk assessment

Will vaccination raise the incidence of autoimmune diseases, what is the impact of increasingly crowded vaccination schedules, the vaccination in age groups and the risk of coincidental temporal association? All these issues are still under debate. However, for the time being, to avoid confusion in the medical community and the media, we have to adhere to guidelines established consensually by experts while ensuring a strict surveillance and reporting possible side effects. Recommendation for vaccination in patients with autoimmune inflammatory rheumatic diseases (AIIRD) based on the currently available evidence and expert opinion were recently formulated by an EULAR task force. Major recommendations for AIIRD include: i) vaccination should ideally be administered during stable disease; ii) influenza vaccination and pneumococcal vaccination should be strongly considered; iii) vaccination can be administered during the use of DMARDs and TNF-inhibitors, but before starting rituximab; iv) live attenuated vaccines should be avoided whenever possible in immunosuppressed patients; v) BCG vaccination is not recommended.

[Acute reactive arthritis after intravesical instillation of bacillus Calmette-Guérin. Two case reports and literature review]

INTRODUCTION

Intravesical bacillus Calmette-Guérin (BCG) therapy-associated articular complications are uncommon, occurring in only 0.5 to 1% of the patients.

OBSERVATIONS

We report two patients who were given intravesical BCG therapy for superficial bladder cancer. Both patients developed polyarthritis and fever related to intravesical BCG instillation. The outcome of articular manifestations was favorable after administration of nonsteroidal anti-inflammatory therapy.

CONCLUSION

Intravesical BCG therapy-associated articular complications should not be overlooked, as they may result in high morbidity. Nevertheless, the diagnosis of intravesical BCG therapy-related reactive arthritis should be discussed after excluding infectious arthritis due to Mycobacterium bovis. Therefore, joint fluid microbiological tests (cultures, PCR) are required in the patients receiving intravesical BCG who develop arthritis.

Reiter’s syndrome during intravesical BCG therapy for bladder carcinoma

A 50-year-old male with superficial bladder carcinoma developed fever, conjunctivitis, cystitis, and arthritis of the ankles and metatarsophalangeal and sacroiliac joints after the fourth course of intravesical Bacillus Calmette-Guerin (BCG) therapy. Reiter's syndrome in the context of BCG therapy was diagnosed, and intravesical immunotherapy was discontinued. Treatment with indomethacin was started with partial response, while a significant clinical improvement was noted when prednisolone 30 mg daily was started. One month later, the patient was on full clinical and laboratory remission, and steroid treatment was gradually tapered. Clinicians should be aware of this rare complication of BCG therapy because early diagnosis may lead to early management.

Osteoarticular side effects of BCG therapy

Although osteoarticular side effects of the Bacillus Calmette-Guérin (BCG) are rare compared to the number of administrations, BCG vaccination and cancer therapy are so widely used that the absolute number of cases is not negligible. Osteoarticular infection is an exceedingly rare complication of vaccination with the BCG. Intravesical BCG instillations used to treat superficial bladder cancer may cause arthralgia, reactive arthritis or osteoarticular infections. Intradermal BCG therapy used to treat a number of malignancies can cause osteoarticular infections or bilateral symmetric polyarthritis predominating in the wrists and fingers. In practice, when intravesical BCG instillation is followed by arthritis, hyperthermia is unhelpful for distinguishing septic arthritis from reactive arthritis. Arguments pointing to reactive arthritis include oligo- or polyarticular involvement and onset a few weeks (as opposed to a few months) after the last instillation. Nevertheless, joint fluid examination is in order to rule out septic arthritis. BCG-induced reactive arthritis usually responds well to nonsteroidal anti-inflammatory drugs. Osteoarticular infections related to BCG therapy should be treated by rifampin, isoniazid and ethambutol for 2 months, followed by rifampin and isoniazid for 10 months.

Reactive arthritis following BCG immunotherapy for urinary bladder carcinoma: a systematic review

Intravesical instillation of Bacillus Calmette-Guerin (BCG) is used with efficacy and safety in the treatment of patients with intermediate and high-risk superficial bladder carcinoma. Arthralgia and/or arthritis is one of the rare severe complications following intravesical BCG immunotherapy. We searched MEDLINE in order to analyze the frequency of this clinical complication, its pathogenesis and outcome. The electronic search was conducted using the following key words: "BCG immunotherapy" and "Arthritis, arthralgias and BCG immunotherapy". At the end of a process of abstract analysis, 48 papers were included in the systematic review. All the selected papers, except one that was a clinical review, described at least one case of arthritis after BCG therapy. The BCG immunotherapy resulted to be safe and efficacious in the treatment of bladder cancer; the development of reactive arthritis is rare and can evolve in a chronic process. The review of the literature highlighted that reactive arthritis following BCG intravesical instillation is a complication usually well controlled with the discontinuation of the immunotherapy and nonsteroidal anti-inflammatory drugs (NSAIDs) treatment. Only a small portion of patients with a particular genetic background will develop a chronic process.

Optimal treatment of systemic bacillus Calmette-Guérin infection: investigations in an animal model

PURPOSE

Hematogenous spread of bacillus Calmette-Guerin (BCG) after intravesical instillation for bladder cancer is rare but it may result in systemic infection and hypersensitivity reaction. We investigated fluoroquinolones and steroids in an animal model to improve the therapeutic options in local and systemic BCG infection. Furthermore, the antitumor effectiveness of intravesical BCG with simultaneous application of fluoroquinolones and/or steroids was tested.

MATERIALS AND METHODS

Oral antimicrobial therapy with and without steroids was started immediately after intraperitoneal injection using fluoroquinolones or trimethoprim-sulfamethoxazole. To evaluate the therapeutic options against a hyperergic reaction after repeat systemic BCG infection re-challenge was performed with intraperitoneal BCG 7 days after primary infection and oral therapy was given with fluoroquinolones or trimethoprim-sulfamethoxazole with and without steroids. The influence of continuous oral fluoroquinolone therapy on the antitumor effect of BCG was also tested in the MB 49 orthotopic murine bladder tumor model.

RESULTS

After primary systemic infection fluoroquinolone therapy alone led to significantly prolonged survival in mice (log rank test p = 0.041), whereas trimethoprim-sulfamethoxazole was ineffective. There was no additional effect of steroid administration. Steroids alone led to premature death (log rank test p = 0.022). After secondary BCG infection only steroid treated animals had prolonged survival (log rank test p = 0.032), whereas antimicrobials alone had no effect. The therapeutic efficacy of BCG in the orthotopic bladder tumor model was not affected by continuous oral fluoroquinolones in terms of survival (log rank test p = 0.001) or bladder weight (Wilcoxon test p = 0.001) compared with untreated controls.

CONCLUSIONS

In a mouse model fluoroquinolones had a beneficial effect for primary systemic BCG infections, whereas the hyperergic reaction after repeat BCG infection was susceptible only to steroids. Administering fluoroquinolones during an intravesical treatment course does not affect the antitumor efficacy of BCG.

Epididymo-orchitis following intravesical bacillus Calmette-Guérin therapy

OBJECTIVE

To describe a case of epididymo-orchitis that developed four years after treatment with intravesical bacillus Calmette-Guérin (BCG) and to review the incidence of this adverse effect.

DATA SOURCES

Information about the patient was obtained from the medical chart. A MEDLINE search of English-language literature (from January 1976 to April 1999) was conducted.

STUDY SELECTION

All case reports of BCG-related epididymo-orchitis were evaluated. Review articles describing complications of BCG therapy for bladder cancer and the prevention and treatment of these complications were reviewed.

DATA EXTRACTION

Studies were evaluated for reports of BCG-related epididymo-orchitis and its treatment.

DATA SYNTHESIS

Our case report is compared with others reported in the literature. The incidence of BCG-associated epididymoorchitis is rare.

CONCLUSIONS

Epididymo-orchitis should be considered as a late complication of BCG therapy for bladder cancer. Proper patient selection may help decrease the risk of complications from BCG therapy.