A unique case of miliary pulmonary tuberculosis induced by bacillus Calmette-Guérin intravesical instillation with COVID-19 superinfection

Abstract

Intravesical instillation of Bacillus Calmette-Guérin (BCG) is used as an adjuvant treatment of bladder cancer. Systemic BCG infection occurs in less than 1% of cases, and pulmonary involvement is even rarer (0.3% - 0.7%), with a favourable prognosis. A 78-year-old male developed miliary tuberculosis (TB) secondary to intravesical BCG treatment and subsequent coronavirus disease 2019 (COVID-19) superinfection that led to patient death. High awareness amongst clinicians is needed to proceed with immediate appropriate therapy in these patients, especially during the COVID-19 pandemic.

Keywords: BCG; COVID-19; CT; SARS-CoV-2; tuberculosis.

FIGURE 1

A normal CT of the chest performed before the patient’s access to the Emergency Department (a). A CT scan of the same patient performed 10 days after the last Bacillus Calmette-Guérin instillation, showing 1 mm – 2 mm diameter nodules disseminated throughout the lung and distributed randomly with respect to the lobular structures in a miliary pattern (b). After two weeks of antibiotic therapy, CT imaging revealed a numerical and dimensional increase in the multiple micronodules (c). Despite the administration of anti-tubercular therapy, the patient’s clinical condition deteriorated again, requiring a new CT scan that revealed the presence of bilateral ground-glass opacities localised mainly in the middle and lower parts of the lungs, partially superimposed on the previously seen multiple lung micronodules, compatible with coronavirus disease 2019 superinfection (d).