Concurrent granulomatous hepatitis, pneumonitis and sepsis as a complication of intravesical BCG immunotherapy

Abstract

Intravesical administration of BCG is a relatively simple procedure used successfully in the treatment of superficial transitional cell carcinoma of the urinary bladder. It is usually well tolerated with few major side effects. The authors report the case of an 80-year-old man who presented with sepsis, jaundice, hepatic and pulmonary failure 10 days after his last BCG instillation therapy, that was attributed to concurrent granulomatous hepatitis and pneumonitis due to Mycobacterium bovis dissemination. In rare instances severe life-threatening complications occur in relation with BCG instillation immunotherapy that may involve multiple organs and have different presentations and require a high index of suspicion and clinical awareness in a wide range of medical specialties.

Figure 1

(A) Thoracic CT of the patient before admission demonstrating diffuse bilateral ground glass opacities as well as areas of bronchial wall thickening and ill-defined small nodular opacities in the middle and lower right lobes. (B) Chest X-ray on admission showing a combination of diffuse alveolar opacities and nodules predominantly in the middle and lower lung zones. (C) Thoracic CT of the patient 20 days after antituberculous treatment in combination with low-dose corticosteroids, showing considerable improvement.

Figure 2

Representative microphotographs of the hepatic and lung tissue obtained through CT-guided fine needle biopsy and transbronchial biopsy, respectively. (A) Staining with H&E of hepatic tissue revealing the presence of small epithelioid granulomas in the absence of Langhans giant cells and caseous necrosis. Immunohistochemical staining revealed positivity for CD68 (B) and negativity for cytokeratin 18 (C). A similar granulomatous structure is shown in the lung tissue obtained by transbronchial biopsy in (D).