Bcg
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Systemic BCG infection and mycotic aneurysm (BCG-osis): case report A 79-year-old man developed Systemic BCG infection and mycotic aneurysm (BCG-osis) following treatment with BCG injections for bladder cancer . The man, who was diagnosed with bladder cancer in December 2014 underwent transurethral resectioning and subsequently received 4 courses of intravesicular injections of BCG over a period of 2 years [dosage not stated]. After 8 months of administration of the last dose of BCG, in May 2017, he developed fever, malaise and he also lost 5 kg weight. Laboratory tests showed deranged liver function tests with pancytopenia. An upper GI endoscopy performed for weight loss and anaemia was unremarkable. A CT scan showed reactive coeliac axis lymph nodes. Therefore, a liver biosy was performed that demonstrated small, non-necrotising granulomas in the portal area’ although no any micro-organisms were noted with staining studies. A bone marrow trephine biopsy indicated non-caseating granulomata. Urine culture study was positive for acid fast bacilli and eventually PCR testing showed mycobacterium tuberculosis compatible with BCG-osis. In August 2017, he was diagnosed with systemic BCG infection. The man was treated with isoniazid, rifampicin, ethambutol and pyrazinamide. A month later, due to further derangement of liver function tests and development of an erythematous rash, isoniazid was replaced with moxifloxacin. Between 30 August 2017 and 30 August 2018, he was on a continuous antibiotic therapy. Post-treatment, his symptoms regressed and inflammatory markers remained normal. At the follow up in October 2018, a CT scan showed saccular thoracic aneurysm just distal to the aortic arch, tracking through the ligamentum arteriosum with surrounding inflammatory changes. PET scan confirmed that the aneurysm was metabolically active. On previous CT scans, there were no any abnormalities noted of the thoracic aorta. Considering the time frame of the diagnosis of BCG-osis and appearance of metabolic activity on PET scan, the lesion was suspected to be consistent with mycotic aneurysm. The aneurysm measured 4.8×3.2cm transversely and it grew to 6.4×3.4cm within a period of 5 months. His Creactive protein was also elevated. Subsequently, he underwent thoracic endovascular aortic repair using a stent graft. The graft was placed distal to the left sub-clavian artery with good angiographic results. Post-operatively, he was treated with long-term ceftriaxone, moxifloxacin and rifampicin. At the follow up of 6 weeks, no systemic symptoms were noted on a repeat CT scan. Ribeiro L, et al. Rare case of a proximal descending thoracic aorta mycotic aneurysm following intravesical BCG injections for the treatment of bladder cancer. BMJ Case 803449723 Reports 12: e231595, No. 12, Dec 2019. Available from: URL: http://doi.org/10.1136/bcr-2019-231595
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Reactions 25 Jan 2020 No. 1788
