İntravezikal BCG uygulaması sonrası oluşan miliyer akciğer tüberkülozu olgusu
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Tarih
2023
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info:eu-repo/semantics/openAccess
Özet
Bacillus Calmette-Guerin (BCG) aşısının intravezikal uygulaması, yüzeyel mesane kanseri tedavisinde kullanılmaktadır. Klinik pratikte, orta ve yüksek riskli yüzeyel mesane tümörlerinde, transüretral tümör rezeksiyonu sonrası intravezikal BCG immünoterapisi, tümör nüks ve progresyonunu önlemede oldukça etkili bir tedavi seçeneğidir. Hastalara canlı tüberküloz (TB) basili verildiği için pnömoni, sepsis ve hatta ölüm gibi ciddi yan etkiler görülebilmektedir. Akciğer tutulumu hastaların %1’inden daha azında görülür ve en yaygın olarak interstisyel pnömoni veya miliyer TB olarak ortaya çıkar. Miliyer TB’nin teşhis edilmesi zordur ve çoğu olguda Mycobacterium bovis izole edilmediğinden genellikle yüksek klinik şüpheye dayanır. Tedavi tamamen standardize edilmemiştir. Bununla birlikte ciddi olgularda, antitüberküloz ilaçlar ve kortikosteroidlerin bir kombinasyonu önerilir. Bu olgu raporunda, yüzeyel mesane kanseri tanısı olan hastada, BCG’nin mesaneye instilasyonu sonrası çok nadir görülen bir komplikasyon olan miliyer TB olgusu sunulmuştur. Mesane tümörü tanısı konulan 73 yaşında erkek hastaya, transüretral mesane tümörü rezeksiyonu uygulanmış olup daha sonra altı hafta boyunca haftada bir intravezikal BCG-MEDAC enjeksiyonu yapılmış, herhangi bir yan etki olmamıştır. Sistoskopi ile üç ay sonra kontrol edildiğinde nüks belirtisi olmayan hastaya, üç haftalık intravezikal BCG takviyesi planlanmıştır. İlk dozdan iki saat sonra, üşüme-titreme şikayetiyle acil servise başvuran hasta, idrar ve kan kültürü tetkikleri alınıp ileri takip ve tedavi için hastaneye yatırılmış, ampirik olarak levofloksasin 500 mg başlanmıştır. Sonrasında, geniş spektrumlu antibiyotiklerle (meropenem ve teikoplanin) tedavisinin yedinci gününde ateşi devam eden hastadan tekrar kültürleri alınmıştır. Ek olarak batın ve akciğer bilgisayarlı tomografisi (BT) çekildiğinde, her iki akciğerde miliyer tarzda çok sayıda nodüler lezyon saptanmış ve miliyer TB lehine değerlendirilmiştir. Bu bulgularla hastaya, BCG enjeksiyonu sonrası gelişen enfeksiyon olduğu için Mycobacterium bovis’i hedef alan miliyer TB tedavisi [izoniyazid (INH), rifampisin (RIF), etambutol (EMB) ve streptomisin (STM)] başlanmıştır. Tedavinin üçüncü haftasında hastanın ateşi kontrol altına alınmış, enfeksiyon belirteçlerinde [C-reaktif protein(CRP)-prokalsitonin] belirgin düzelme olduğu için yatışının 25. gününde taburcu edilmiştir. İki ayın sonunda, kontrol toraks BT’de pulmoner anormalliklerde bariz gerileme olduğu saptanmıştır. Sonuç olarak, intravezikal BCG instilasyonu sonrasında gelişen miliyer TB; çok nadir görülen, nedeni tam olarak anlaşılamayan, ateş etiyolojisinde kolayca atlanabilen ve tanısı zor konulan bir durumdur. Bu olgu raporu, tedavi ve takibi uzun süren, oldukça dikkat gerektiren kritik bir hastalık tablosuna dikkat çekmek amacıyla sunulmuştur.
Intravesical administration of Bacillus Calmette-Guerin (BCG) vaccine is used in the treatment of superficial bladder cancer. In clinical practice, intravesical BCG immunotherapy after transurethral tumor resection is a highly effective treatment option in preventing tumor recurrence and progression in medium and high risk superficial bladder tumors. Since patients are given live tuberculosis (TB) bacillus, serious side effects such as pneumonia, sepsis and even death can be seen. Lung involvement occurs in less than 1% of patients and most commonly presents as interstitial pneumonia or miliary TB. Miliary TB is difficult to diagnose and is usually based on high clinical suspicion, as Mycobacterium bovis is not isolated in most cases. Treatment is not completely standardized. However, in severe cases, a combination of antituberculosis drugs and corticosteroids is recommended. In this report, a case of miliary tuberculosis, a very rare complication after instillation of BCG into the bladder in a patient with a diagnosis of superficial bladder cancer, was presented. A 73-year-old male patient diagnosed with bladder tumor underwent transurethral resection of bladder tumor, and then weekly intravesical injection of BCG-MEDAC for six weeks had no adverse effects. Three weeks of intravesical BCG supplementation was planned for the patient who had no signs of recurrence when checked three months later by cystoscopy. Two hours after the first dose, the patient, who applied to the emergency department with the complaint of chills and shivering, was hospitalized for further follow-up and treatment. Afterwards, repeat cultures were taken from the patient whose fever continued on the seventh day of treatment with broad-spectrum antibiotics (meropenem and teicoplanin). In addition, when abdominal and thorax computed tomography (CT) were performed, multiple miliary nodular lesions were detected in both lungs and were evaluated in favor of miliary TB. With these findings, the patient was started on miliary TB therapy [isoniazid (INH), rifampicin (RIF), ethambutol (EMB) and streptomycin (STM)] targeting Mycobacterium bovis, since it was an infection that developed after BCG injection. In the third week of the treatment, the patient’s fever was under control, and he was discharged on the 25th day of his hospitalization because of significant improvement in infection markers [C-reactive protein(CRP)-procalcitonin]. At the end of two months, there was clear regression of pulmonary abnormalities on control thorax CT. In conclusion, miliary TB developing after intravesical BCG instillation is a very rare condition, the cause of which is not fully understood, the etiology of fever can be easily missed, and the diagnosis is difficult. In addition, this case is presented to draw attention to a critical disease that requires long treatment and follow-up and requires attention.
Intravesical administration of Bacillus Calmette-Guerin (BCG) vaccine is used in the treatment of superficial bladder cancer. In clinical practice, intravesical BCG immunotherapy after transurethral tumor resection is a highly effective treatment option in preventing tumor recurrence and progression in medium and high risk superficial bladder tumors. Since patients are given live tuberculosis (TB) bacillus, serious side effects such as pneumonia, sepsis and even death can be seen. Lung involvement occurs in less than 1% of patients and most commonly presents as interstitial pneumonia or miliary TB. Miliary TB is difficult to diagnose and is usually based on high clinical suspicion, as Mycobacterium bovis is not isolated in most cases. Treatment is not completely standardized. However, in severe cases, a combination of antituberculosis drugs and corticosteroids is recommended. In this report, a case of miliary tuberculosis, a very rare complication after instillation of BCG into the bladder in a patient with a diagnosis of superficial bladder cancer, was presented. A 73-year-old male patient diagnosed with bladder tumor underwent transurethral resection of bladder tumor, and then weekly intravesical injection of BCG-MEDAC for six weeks had no adverse effects. Three weeks of intravesical BCG supplementation was planned for the patient who had no signs of recurrence when checked three months later by cystoscopy. Two hours after the first dose, the patient, who applied to the emergency department with the complaint of chills and shivering, was hospitalized for further follow-up and treatment. Afterwards, repeat cultures were taken from the patient whose fever continued on the seventh day of treatment with broad-spectrum antibiotics (meropenem and teicoplanin). In addition, when abdominal and thorax computed tomography (CT) were performed, multiple miliary nodular lesions were detected in both lungs and were evaluated in favor of miliary TB. With these findings, the patient was started on miliary TB therapy [isoniazid (INH), rifampicin (RIF), ethambutol (EMB) and streptomycin (STM)] targeting Mycobacterium bovis, since it was an infection that developed after BCG injection. In the third week of the treatment, the patient’s fever was under control, and he was discharged on the 25th day of his hospitalization because of significant improvement in infection markers [C-reactive protein(CRP)-procalcitonin]. At the end of two months, there was clear regression of pulmonary abnormalities on control thorax CT. In conclusion, miliary TB developing after intravesical BCG instillation is a very rare condition, the cause of which is not fully understood, the etiology of fever can be easily missed, and the diagnosis is difficult. In addition, this case is presented to draw attention to a critical disease that requires long treatment and follow-up and requires attention.
Açıklama
Anahtar Kelimeler
İntravezikal BCG uygulaması, Miliyer akciğer tüberkülozu, Mesane kanseri, Intravesical BCG instillation, Miliary pulmonary tuberculosis, Bladder cancer
Kaynak
Mikrobiyol Bul
WoS Q Değeri
Scopus Q Değeri
Q4
Cilt
57
Sayı
4
Künye
Gözüküçük, R., & Çakıroğlu, B. (2023). Miliary Pulmonary Tuberculosis After Intravesical BCG Instillation in a Patient with High-Grade Bladder Cancer. Mikrobiyoloji Bulteni, 57(4), 675–681. https://doi.org/10.5578/mb.20239955
