A late presentation of isolated lymph node tuberculosis postintravesical BCG therapy for superficial bladder cancer: a novel case

Abstract

Intravesical BCG immunotherapy is commonly used in the treatment of superficial bladder cancer. We recount the case of an 82-year-old British man who completed a course of BCG immunotherapy in 2011 for superficial bladder cancer, and presented in January 2013 with a loss of appetite, loss of weight and severe back pain. CT scanning, followed by MRI displayed a 5.7 cm × 5 cm conglomerated necrotic, haemorrhagic mass of lymph nodes in the para-aortic region. A CT-guided biopsy revealed granulomatous inflammation, focal fibrosis and acid-fast bacilli consistent with Mycobacterium tuberculosis (TB). The patient was treated with combination antituberculous medication, and is recovering. To our knowledge, this is the only reported case of lymph node TB secondary to intravesical BCG immunotherapy. We suggest that in patients treated with postintravesical BCG with enlarged lymph nodes, a diagnosis of secondary TB should be considered.

Figure 1

CT axial slice of the abdomen, displaying the necrotic lymph node conglomeration anteriorly and to the right of the abdominal aorta.

Figure 2

(A) MRI saggital slice of the spine, demonstrating the large lymph node mass abutting the spinal column resulting in spondylodiscitis. (B) MRI axial slice of the abdomen, displaying the same lymph node mass. Its proximity to the inferior vena cava is seen.

Figure 3

(A) Photomicrograph (×400) (A) showing acid-fast bacilli on Ziehl-Neelson staining and (B) displaying acid-fast bacilli on Ziehl-Neelson staining.

Figure 4

Photomicrograph (×400) displaying caseation necrosis on H&E staining.

Figure 5

CT saggital slice of the abdomen, showing a significant reduction in size of the lymph node mass after 5 months of antituberculos treatment.