Haemophagocytic lymphohistiocytosis after intravesical BCG administration for bladder cancer presenting with multiorgan failure

Abstract

Bacillus Calmette-Guérin (BCG), is administered intravesically as an adjuvant immunotherapy for the treatment of non-muscle invasive bladder cancer. While mild non-infectious problems can occur in up to 85 % of cases, significant local and systemic complications have been reported in 1-5 % of cases. We report the case of a patient with superficial bladder cancer who developed multiorgan failure after intravesical BCG instillation including the kidney and liver with subsequent haemophagocytic lymphohistiocytosis. Our case illustrates the first reported combination of secondary haemophagocytic lymphohistiocytosis with severe renal and liver failure after BCG immunotherapy for bladder carcinoma. Treatment strategy is discussed.

Keywords: BCG; haemophagocytosis; intravesical; kidney injury; liver failure.

Fig. 1.

(a). May-Grunwald-Giemsa stain of patient’s bone marrow aspirate showing active haemophagocytosis (arrows). Erythroid hyperplasia, with mild reactive dysplasia, at several maturation stages can be observed. Reversal of the normal myeloid/eryhroid ratio is also shown. Of note, myeloid lineage is maturing without morphologic abnormalities. Light microscopy, ×100. (b). May-Grunwald-Giemsa stain of patient’s bone marrow aspirate showing active haemophagocytosis of erythroblasts (arrows) from bone marrow stromal cells (arrow heads). Marked erythroid hyperplasia and reversal of the normal myeloid to erythroid ratio is again depicted. Light microscopy, ×100. (c). Hematoxylin-eosin stained histologic section of bone marrow biopsy specimen showing a well-formed granuloma with several histiocytes (arrow heads) and a Langerhans giant cell (arrow). Light microscopy, ×40. (d). Histologic section of bone marrow biopsy specimen stained for CD68/KP-1 showing markedly positive (brown) granuloma histiocytes. Light microscopy, ×40.