Nearly Fatal Complications of Cervical Lymphadenitis following BCG Immunotherapy for Superficial Bladder CancerGeldmacher H.a · Taube C.a · Markert U.b · Kirsten D.K.a
aKrankenhaus Grosshansdorf, Zentrum für Pneumologie und Thoraxchirurgie, Grosshansdorf, and bKlinik für Chirurgie, Klinikum der Medizinischen Universität zu Lübeck, Lübeck, Deutschland
This report describes the case of a 68-year-old man with bilateral cervical lymphadenitis and chorioretinitis due to bacille Calmette-Guérin (BCG), originating from BCG immunotherapy for treatment of superficial bladder cancer 2 years ago. During antimycobacterial therapy a fistula between the right-sided lymph node and an aneurysm of the carotid artery developed. This led to life-threatening spontaneous bleeding which required vascular graft surgery. Like other known systemic side effects, cervical lymphadenitis may also occur following intravesical BCG immunotherapy, and life-threatening complications cannot be excluded despite adequate medical treatment.
Copyright © 2001 S. Karger AG, Basel
A 68-year-old man was admitted to hospital in March 1999 because of bilateral cervical masses. He had been well until 3 weeks before admission when he noticed bilateral neck swelling. Because of progressive enlargement he was sent to hospital for further evaluation. Otherwise the patient was symptom free and in a good state of health. Two years before admission he was treated for superficial bladder carcinoma with transurethral resection, followed by immunotherapy with bacille Calmette-Guérin (BCG). After the third course of intravesical application, a short episode of subfebrile temperature and malaise occurred, which resolved spontaneously and the patient was symptom free in the following years.
Physical examination on admission demonstrated bilateral cervical masses which were painful to pressure and measured about 5 × 6 cm each. Ophthalmoscopic inspection showed signs of chorioretinitis but further physical examination revealed no other abnormalities. Laboratory blood tests revealed an increased erythrocyte sedimentation rate; however, all other hematological and biochemical parameters were within the normal range. Chest X-ray and abdominal ultrasound were also normal while tuberculin skin test (dose of 10 tuberculin units) was positive. Cervical ultrasound detected 5 × 5 cm hypodense lymph nodes on both sides. An ultrasound-guided fine-needle aspiration was performed on the right side for further diagnosis. The cytologic analysis of the Giemsa-stained slide showed masses of granulocytes, while on a Ziehl-Neelsen-stained slide acid-fast bacilli were detected. These findings led to the diagnosis of tuberculosis with suspected retinal involvement. Antibiotic Therapy was started including isoniazid, rifampicin and pyrazinamide (PZA). After 2 weeks, a further enlargement of the left-sided lymph nodes was found, while on the right side the lymph node ruptured and ulceration became visible. Medication was continued and after another 5 weeks results of the culture showed growth of Mycobacterium bovis var. BCG, leading to the diagnosis of BCG-induced lymphadenitis and chorioretinitis. Having obtained the results of microbial sensitivity testing, PZA was replaced by ethambutol. Under this treatment regimen, the swelling decreased on both sides, while on the right side the ulceration persisted (fig. 1) and repeat ophthalmoscopic evaluation showed remission of the chorioretinitis. On day 61 after initiation of therapy, bright red pulsating bleeding suddenly started from the cervical ulceration. Doppler evaluation showed an aneurysm of the right-sided carotid artery and a fistula between the aneurysm and the ulceration. Immediate operation verified this finding and a vascular graft with the right vena saphena magna was performed. The postoperative period was uncomplicated and the patient recovered without any deficits.
Fig. 1. Patient three weeks after admission showing swelling of bilateral cervical lymph nodes and an ulcerative lesion on the right side.
Intravesical BCG immunotherapy, i.e. administration of an attenuated variant of M. bovis, has gained increased acceptance and is widely used in the treatment of patients with superficial bladder cancer . With the more widespread use of this method, several side effects have been recognized. Local complications, such as granulomatous prostatitis, epididymitis, contracted bladder, hematuria and urethral obstruction have been described. In a series of 2,602 patients, local complications of BCG immunotherapy occurred in about 3% of patients . General side effects like fever, renal abscess, sepsis and BCG-induced pulmonary [3, 4, 5] and miliary tuberculosis [6, 7] are rare and mainly reported in the form of case reports. Therefore the true incidence of systemic side effects remains unknown. Tuberculous lymphadenitis is one of the leading manifestations of extrapulmonary tuberculosis and cervical lymphadenitis with ulceration is a known complication of BCG vaccination . However, so far, there has been no report either of cervical lymphadenitis or of chorioretinitis as a consequence of intravesical BCG immunotherapy. The present case proves that following BCG immunotherapy, cervical lymphadenitis and chorioretinitis may occur. In lymphadenitis, the specific inflammatory reaction can also involve surrounding tissues and may lead to severe complications. Therefore even in immunocompetent patients the course of the disease may be life-threatening in spite of an adequate antituberculosis treatment.
Prof. Dr. med. D.K. Kirsten
Krankenhaus Grosshansdorf, Zentrum für Pneumologie und Thoraxchirurgie
D–22927 Grosshansdorf (Germany)
Tel. +49 4102 6010, Fax +49 4102 692 295, E-Mail Hgeldmache@aol.com
Received: Received: May 22, 2000
Accepted: December 17, 2000
Number of Print Pages : 2
Number of Figures : 1, Number of Tables : 0, Number of References : 8
Respiration (International Review of Thoracic Diseases)
Founded 1944 as ‘Schweizerische Zeitschrift für Tuberkulose und Pneumonologie’ by E. Bachmann, M. Gilbert, F. Häberlin, W. Löffler, P. Steiner and E. Uehlinger, continued 1962–1967 as ‘Medicina Thoracalis’
Vol. 68, No. 4, Year 2001 (Cover Date: July-August 2001)
Journal Editor: C.T. Bolliger, Cape Town
ISSN: 0025–7931 (print), 1423–0356 (Online)
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