B103-13 Intravesical to Invasive: Systemic BCGitis as a Diagnosis of Exclusion

Abstract Introduction Intravesical Bacillus Calmette-Guérin (BCG) therapy, an attenuated Mycobacterium Bovis, is a common therapy for certain types of bladder cancer. Complications range from chemical or bacterial cystitis to multiorgan hypersensitivity reaction or disseminated BCG infection. Systemic reaction to intravesical BCG, or BCGitis, has an incidence of 2%. Its pathogenesis is suspected to be caused by disseminated infection versus a type IV hypersensitivity reaction, though likely these are a spectrum of pathologies. Herein we present a case of BCGitis leading to multisystem organ failure. Case Report An 85-year-old man with interstitial lung disease (ILD) of unclear etiology and history of bladder cancer on intravesical BCG, presents with fever, altered mentation, and hematuria. The patient received BCG instillation with mucosal trauma the day prior with subsequent hematuria and dysuria. He was treated for bacterial cystitis but urine cultures remained negative and diagnosis shifted to local BCG hypersensitivity with chemical cystitis. The patient developed spiking fevers, hypoxic respiratory failure, and transaminitis. Treatments were initiated for pneumonia and an ILD flare. Despite treatment, he clinically deteriorated prompting BCGitis treatment initiation on day 12 of hospitalization. Lung and liver biopsies were deferred due to instability and the patient expired on day 28 of hospitalization. Autopsy revealed granulomatous changes in the liver, lung, and prostate, with foci of prostate AFB positivity consistent with systemic BCGitis. Discussion The lungs and liver are commonly affected in BCGitis, but alternative diagnoses were initially considered due to rarity of BCGitis and the patient’s comorbid conditions. As in this patient, diagnosis is difficult and can be one of exclusion, with nonspecific imaging findings (Figure 1), 60% of biopsies with granulomas, and 50% with positive microbiologic evidence. Studies on treatment are limited; recommended therapy includes antimycobacterial medications with corticosteroids to treat components of infection and hypersensitivity. Risk factors include bladder trauma, diabetes mellitus, immunosuppression, and genetic susceptibility. Traumatic instillation raised suspicion for BCGitis in this patient. BCGitis can have early or late presentations with varying organ involvement depending on time since last instillation. Depending on organ involvement, mortality can be up to 17.5%, thus treatment should not be delayed, especially in those older than 65 that have increased risk of mortality. To optimize outcomes, clinicians need a high index of suspicion and should consider early treatment for BCGitis in patients with multiorgan dysfunction and a history of intravesical BCG treatment, especially in those with comorbidities and negative microbiologic data. This abstract is funded by: None