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Vol. 68, No. 4, 2001
Issue release date: July–August 2001
Section title: Case Report
Respiration 2001;68:420–421
(DOI:10.1159/000050539)

Nearly Fatal Complications of Cervical Lymphadenitis following BCG Immunotherapy for Superficial Bladder Cancer

Geldmacher 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
email Corresponding Author

Abstract

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.

© 2001 S. Karger AG, Basel


  

Key Words

  • BCG immunotherapy
  • Superficial bladder cancer
  • Lymphadenitis
  • Chorioretinitis

 case report

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.

FIG01

Fig. 1. Patient three weeks after admission showing swelling of bilateral cervical lymph nodes and an ulcerative lesion on the right side.

 

 discussion

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 [1]. 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 [2]. 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 [8]. 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.


References

  1. Grange JM: Complications of bacille Calmette-Guérin (BCG) vaccination and immunotherapy and their management. Commun Dis Public Health 1998;1:84–88.
  2. Gupta RG, Langengood R, Smith JP: Miliary tuberculosis due to intravesical bacillus Calmette-Guérin therapy. Chest 1988;94:1296–1298.
  3. Foster DR: Miliary tuberculosis following intravesical BCG treatment. Br J Radiol 1997;70:429.
  4. LeMense GP, Strange C: Granulomatous pneumonitis following intravesical BCG. Chest 1994;106:1624–1626.
  5. Israel-Biet D, Sabdron VD, Zizza JM, Chretien J: Pulmonary complications of intravesical bacillus Calmette-Guérin administration for bladder cancer. Am Rev Respir Dis 1987;135:763–765.

    External Resources

  6. Kirsten D, Rieger U, Schröder KH, Böhle A, Magnussen H: Pulmonary tuberculosis due to bacille Calmette-Guérin. Clin Investig 1993;71:787–790.
  7. Lamm DL, Steg A, Boccon-Gibod L: Complications of bacillus Calmette-Guérin immunotherapy: A review of 2,602 patients and comparison of chemotherapy complications. Prog Clin Biol Res 1989;310:335–355.
  8. Shellhammer PF, Ladaga LE, Fillion MB: Bacillus Calmette-Guérin for superficial transitional cell carcinoma of the bladder. J Urol 1986;135:261.

    External Resources

  

Author Contacts

Prof. Dr. med. D.K. Kirsten
Krankenhaus Grosshansdorf, Zentrum für Pneumologie und Thoraxchirurgie
Wöhrendamm 80
D–22927 Grosshansdorf (Germany)
Tel. +49 4102 6010, Fax +49 4102 692 295, E-Mail Hgeldmache@aol.com

  

Article Information

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

  

Publication Details

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)

For additional information: http://www.karger.com/journals/res


Copyright / Drug Dosage / Disclaimer

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

Abstract

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.

© 2001 S. Karger AG, Basel


  

Author Contacts

Prof. Dr. med. D.K. Kirsten
Krankenhaus Grosshansdorf, Zentrum für Pneumologie und Thoraxchirurgie
Wöhrendamm 80
D–22927 Grosshansdorf (Germany)
Tel. +49 4102 6010, Fax +49 4102 692 295, E-Mail Hgeldmache@aol.com

  

Article Information

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

  

Publication Details

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)

For additional information: http://www.karger.com/journals/res


Article / Publication Details

First-Page Preview
Abstract of Case Report

Published online: 7/27/2001
Issue release date: July–August 2001

Number of Print Pages: 2
Number of Figures: 1
Number of Tables: 0

ISSN: 0025-7931 (Print)
eISSN: 1423-0356 (Online)

For additional information: http://www.karger.com/RES


Copyright / Drug Dosage

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

References

  1. Grange JM: Complications of bacille Calmette-Guérin (BCG) vaccination and immunotherapy and their management. Commun Dis Public Health 1998;1:84–88.
  2. Gupta RG, Langengood R, Smith JP: Miliary tuberculosis due to intravesical bacillus Calmette-Guérin therapy. Chest 1988;94:1296–1298.
  3. Foster DR: Miliary tuberculosis following intravesical BCG treatment. Br J Radiol 1997;70:429.
  4. LeMense GP, Strange C: Granulomatous pneumonitis following intravesical BCG. Chest 1994;106:1624–1626.
  5. Israel-Biet D, Sabdron VD, Zizza JM, Chretien J: Pulmonary complications of intravesical bacillus Calmette-Guérin administration for bladder cancer. Am Rev Respir Dis 1987;135:763–765.

    External Resources

  6. Kirsten D, Rieger U, Schröder KH, Böhle A, Magnussen H: Pulmonary tuberculosis due to bacille Calmette-Guérin. Clin Investig 1993;71:787–790.
  7. Lamm DL, Steg A, Boccon-Gibod L: Complications of bacillus Calmette-Guérin immunotherapy: A review of 2,602 patients and comparison of chemotherapy complications. Prog Clin Biol Res 1989;310:335–355.
  8. Shellhammer PF, Ladaga LE, Fillion MB: Bacillus Calmette-Guérin for superficial transitional cell carcinoma of the bladder. J Urol 1986;135:261.

    External Resources