BCG
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BCG Fever and rupture of tuberculous infective abdominal aortic aneurysm secondary to BCG infection: case report
A man in his 70s’ [exact age not stated] developed fever and rupture of tuberculous infective abdominal aortic aneurysm secondary to BCG infection during treatment with BCG instillation therapy for carcinoma of the bladder. The man, who had carcinoma of the bladder underwent intravesical BCG instillation therapy from October 2016 to June 2017. Thereafter, the administration was discontinued due to development of fever. In early September 2018, at the age of 74 years (1 year and 3 months post the BCG instillation therapy) he developed pain from his left hip to his thigh, and he was put on follow-up observation while on unspecified analgesics. Additionally, from the middle of the month, he developed abdominal pain and fever. Thus, he was then hospitalised and examined. A contrast CT showed findings of abdominal aortic aneurysm rupture and iliopsoas abscess. Physical findings showed SpO2 98%, BP 125/74mm Hg, HR 83 times/minutes, body temperature 37.5°C. His abdomen was found to be distended and soft. He had decreased intestinal peristaltic sound, and there was tenderness from the left lower abdomen to the left inguinal region. His dorsal artery of the foot was found to be palpable. Laboratory investigation revealed WBC 8310 /µL, Hb 10.4 g/dL, platelet count 27.2 x 104/µL, blood urea nitrogen 18.2 mg/dL, creatinine 0.75 mg/dL, CRP 14.21 mg/dL and procalcitonin 0.39 ng/mL. His thoraco-abdominal contrast CT findings revealed pseudoaneurysm in the renal artery submandibular aorta and left common iliac artery. Additionally, haematoma and abscess were noted on the left side of the retroperitoneal space. Based on the findings, infectious aneurysm rupture was considered. Thus, the man underwent semi-emergency surgery consisting replacement of the abdominal aorta with a synthetic graft, iliopsoas abscess debridement and omentopexy. A rifampicin-bonded synthetic graft was utilised due to possibility of tuberculous involvement following BCG instillation therapy. Investigations of tissues collected during surgery were positive for tuberculosis DNA in a PCR, and revealed multiple giant cell granulomas with caseous necrosis, which strongly suggested tuberculosis involvement. He was then treated with oral anti-tuberculars comprising ethambutol, isoniazid, pyrazinamide and rifampicin [dosages not stated]. The post-operative CT revealed no findings such as anastomotic pseudoaneurysm, and the abscess also showed a shrinking tendency. On post-operative day 20, he developed acute purulent cholangitis, and was transferred to the Gastroenterology department. Because of prolonged hepatic dysfunction [aetiologies not stated], his oral anti-tuberculars were discontinued on post-operative day 40. Thereafter, he had no subsequent recurrence of tuberculosis, and he was discharged home on post-operative Day 62 [not all outcomes stated]. Koga Y, et al. [Rupture of Tuberculous Infective Abdominal Aortic Aneurysm after Intravesical
