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Case Reports
. 2011 Sep 30:11:260.
doi: 10.1186/1471-2334-11-260.

Granulomatous hepatitis, choroiditis and aortoduodenal fistula complicating intravesical Bacillus Calmette-Guérin therapy: Case report

Cindy Q Gao  1 , Rozina Mithani, Jack Leya, Lesley Dawravoo, Arvin Bhatia, John Antoine, Felipe De Alba, Peter A Russo, Claus J Fimmel
Affiliations
Case Reports

Granulomatous hepatitis, choroiditis and aortoduodenal fistula complicating intravesical Bacillus Calmette-Guérin therapy: Case report

Cindy Q Gao et al. BMC Infect Dis. .

Abstract

Background: Intravesical instillation of Bacillus Calmette-Guérin (BCG) is the treatment of choice for superficial bladder carcinoma. Complications of BCG therapy include local infections and disseminated BCG infection with multiple endorgan complications.

Case presentation: We report a case of disseminated, post-treatment BCG infection that initially presented with granulomatous hepatitis and choroiditis. After successful anti-mycobacterial therapy and resolution of the hepatic and ocular abnormalities, the patient developed an acute upper gastrointestinal hemorrhage from an aortoduodenal fistula that required emergency surgery. The resection specimen revealed multifocal, non-caseating granulomas, indicating mycobacterial involvement.

Conclusions: This case highlights the varied end organ complications of disseminated BCG infection, and the need for vigilance even in immuno-competent patients with a history of intravesical BCG treatment.

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Figures

Figure 1
Figure 1
Patient's weight and Alkaline Phosphatase changes prior to BCG instillation, during and after antimycobacterial treatment (BCG Rx: BCG treatment; First Sx: first symptom; TB Rx: TB treatment)
Figure 2
Figure 2
Pathological features of liver biopsy of granulomatous hepatitis. Multiple non-caseating granulomas (A, ×10) and typical Langerhans giant cells (B, ×40).
Figure 3
Figure 3
Bone marrow involvement with Mycobacterium bovis. Multiple non-caseating granulomas (arrows) with Langerhans giant cells (A. ×10). B. Higher magnification (×20).
Figure 4
Figure 4
Ophthalmoscopic findings (multiple, circumscribed yellow-creamy lesions) of bilateral choroiditis with greater severity in the left eye.
Figure 5
Figure 5
Duodenal pathology of aorto-duodenal fistula. A. (×4) single, small, non-caseating granuloma with multinucleated foreign body giant cell reaction (arrow) and chronic transmural inflammation with vascular congestion, consistent with a fistula. L(lumen), m(mucosa), sm(submucosa), mp(musularis propria). B. Close-up view of duodenal pathology. (×10) Non caseating granuloma with Langerhans giant cell (arrow).
See this image and copyright information in PMC

References

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