BCG
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Disseminated bacillus calmette-guerin infection: case report A 79-year-old man developed disseminated bacillus calmette-guerin (BCG) infection following treatment with BCG for bladder cancer. The man, who had a history of multiple malignancies including adenocarcinoma of the prostrate and lungs, treated with radiotherapy, presented in October 2017 with haematuria. He was diagnosed with bladder cancer. He received a single instillation of mitomycin. Histology showed high-grade non-muscle invasive urogenital carcinoma (Grade 3). He started receiving treatment with standard 15 BCG [Bacillus Calmette-Guerin]instillations from January 2018, consisting of six instillations for induction and three instillations for maintenance. He received the tenth BCG instillation in September 2018 and developed shivers, resolved within 4 days. One week later, after the eleventh BCG instillation, he developed persistent fever and urinary retention. The man’s BCG therapy was interrupted. He was admitted and received empirical amoxicillin/clavulanic acid [co-amoxiclav] and ciprofloxacin for urinary tract infection. He was trained to self-catheterise for urinary retention and discharged. Urine cultures obtained at the start of therapy returned normal. In mid-October 2018, a fortnight after his discharge, his fever continued. As he was reluctant to visit hospital, a team visited him and he was re-admitted two days later. Upon admission, he showed the following laboratory results: BP of 135/90mm Hg, body temperature of 38.5°C, respiratory rate of 20 breaths/minute with 91% saturation on air and HR of 79 bmp. His initial examination showed he was mildly inattentive but orientated. He also showed non-icteric sclerae and dry mucous membranes. Fine crepitations in the right lower zone were noted on auscultation, with normal heart sounds. He did not show organomegaly and his abdomen was soft and non-tender. A bladder scan showed residual volume of 400mL. Further testing revealed pancytopenia and newly deranged liver biochemistry. A CT scan of the chest, abdomen and pelvis showed dispersed multifocal areas of consolidation with right-sided pleural effusion, which was too small to aspirate. He received cefuroxime and metronidazole for fever, but it persisted even after 72 hrs of treatment. He did not have a history of tuberculosis. Hence, disseminated BCG infection was suspected and on 26 October 2018, he was empirically treated with rifampicin, isoniazid and ethambutol. Nine days later, his fever resolved as he showed clinical improvement. He had been bedridden and could now sit out of bed. He also became more attentive. However, his liver biochemistry deteriorated further to ALT levels of 241 and bilirubin of 102 [units not stated] on day 12 of therapy. On day 13, his treatment was switched to ethambutol, levofloxacin and amikacin. His liver biochemistry normalised and his original treatment was re-started. He showed gradual recovery and was able to walk around the ward. His delirium also resolved. He was discharged home with physiotherapy s
