대한흉부영상의학회 Weekly Chest Cases

Case No : 1423 Date 2025-01-27

Courtesy of Dong Young Jeong, Ho Yun Lee / Samsung Medical Center
Age/Sex 76 / M
Chief ComplaintFever. History of bladder cancer (treated with TUB-B and intravesical immunotherapy)

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Diagnosis With Brief Discussion

Diagnosis: Disseminated BCG infection
Radiologic Findings: 1) Miliary nodules without significant lymphadenopathy in both lungs.
2) Heterogenous FDG uptake in both lungs
Brief Review: Bacille Calmette–Guérin (BCG) therapy is a well-tolerated and effective treatment for superficial bladder cancer. However, rare systemic complications, known as disseminated BCG infection or "BCGitis," can occur in fewer than 5% of cases.
Diagnosing BCGitis is challenging because microbiological evidence is absent in at least half of the cases. It should be suspected in patients presenting with moderate-to-severe genitourinary or systemic symptoms following intravesical BCG instillation, especially when symptoms improve with anti-tuberculosis therapy and other diagnoses are excluded. Sepsis is the most severe manifestation, but other organ systems, such as the liver and bones, may also be affected. Pulmonary involvement is particularly rare, occurring in only 0.3–0.7% of cases, and often presents as interstitial pneumonitis or miliary dissemination. The condition likely results from a combination of mycobacteraemia and hypersensitivity-driven inflammation at various sites. Risk factors for BCGitis include host characteristics, such as the extent of bladder mucosal damage and immunodeficiency, which are considered more important than therapeutic regimen features.
Severe cases are managed with a combination of anti-tuberculosis drugs and corticosteroids, though standardized treatment protocols are lacking.
In some case reports, simple discontinuation of BCG alone was sufficient like our case. Venn et al. illustrated a case who had febrile illness for more than one month with persisting pulmonary nodules, that improved without any treatment. The authors suggested that some pulmonary reactions, with mild initial presentation, may resolve spontaneously, whether due to hypersensitivity or natural clearance of BCG
Imaging features of BCGitis mimic the disseminated tuberculosis infection. Pulmonary BCGitis can closely mimic the imaging features of miliary tuberculosis, as observed in this case. BCG-hepatitis may present with non-specific findings such as hepatomegaly and ascites. Vascular complications, commonly involving the abdominal aorta, often manifest as saccular aneurysms or pseudoaneurysms, with signs of overt or impending rupture frequently reported. Paraspinal and psoas abscesses can also occur, typically in association with BCG-spondylodiscitis or secondary to the local spread of aortic infections. PET/CT findings are also non-specific and may overlap with other granulomatous or infectious diseases.
References: 1. Bowyer, L., et al. "The persistence of bacille Calmette‐Guérin in the bladder after intravesical treatment for bladder cancer." British journal of urology 75.2 (1995): 188-192.
2. Macleod, Liam C., Tin C. Ngo, and Mark L. Gonzalgo. "Complications of intravesical bacillus Calmette-Guerin." Canadian Urological Association Journal 8.7-8 (2014): E540.
3. Venn, Robert Michael, and Neel Sharma. "Resolution without treatment of granulomatous pneumonitis due to intravesical BCG for bladder cancer." Case Reports 2014 (2014): bcr2014204440.
4. Jasmer, Robert M., Marcia J. McCowin, and W. Richard Webb. "Miliary lung disease after intravesical bacillus Calmette-Guérin immunotherapy." Radiology 201.1 (1996): 43-44.
5. Vilares, Ana T., et al. "Multisystemic BCGitis: A rare complication of intravesical BCG immunotherapy for bladder cancer." Radiology Case Reports 17.7 (2022): 2383-2387.
Keywords

No. of Applicants : 65

▶ Correct Answer : 22/65, 33.8%

- , Japan SUZUNE TSUKAMOTO
- , Japan ISSEI FUKUDA
- , India ABNA J
- Shiga University of Medical Science , Japan AKITOSHI INOUE
- Kyoto University , Japan AKIHIKO SAKATA
- M P Shah Medical College Jamnagar Gujarat , India AKSHAY PARAMESHWAR PENDKAR
- Oita university , Japan AYUMI KAMEI
- Healthy Longevity Medical Center , Japan SHIN-ICHI CHO
- Vita Hospital , Brazil DIOGO LAGO PINHEIRO
- Secomedic Hospital , Japan FUMINORI MIYOSHI
- University of Yamanashi , Japan TAKAAKI HASHIMOTO
- University of Yamanashi , Japan HIROYUKI MORISAKA
- , Japan YOSHIKI ISHII
- University of Yamanashi , Japan HIROAKI WATANABE
- Presbyterian Medical Center , Korea (South) HANLIM SONG
- , Japan MARINO TANIGUCHI
- Osaka metropolitan university Hospital , Japan TATSUSHI OURA
- Kyoto University , Japan SHO KOYASU
- , Japan SHUHEI NORIMOTO
- Kyung Hee University Medical Hospital , Korea (South) JEONG TAEK YOON
- Fukuoka university , Japan KEISUKE SATO
- Toyota Kosei Hospital , Japan YUKI HAYASHI

▶ Correct Answer as Differential Diagnosis : 2/65, 3.1%

- Yonsei University College of Medicine , Korea (South) INSUNG CHO
- , Japan YUMI MAEHARA

▶ Semi-Correct Answer : 19/65, 29.2%

- Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
- Kyoto City Hospital , Japan YUSUKE UTSUNOMIYA
- , Korea (South) DONG-HO BANG
- Seoul Medical Center , Korea (South) HYUK GI HONG
- university of montreal , Canada Andrei Bogdan Gorgos I
- Osaka University , Japan AKINORI HATA
- Other , Korea (South) HYEON IL CHOI
- The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
- , Japan KENTARO KOTANI
- Other , Korea (South) CHAEHUN LIM
- , Japan SHUNJIRO NOGUCHI
- University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
- Mie university , Japan SHIKO OKABE
- GHICL , France MANUEL TOLEDANO
- TB centre kasaragod. , India rikhy krishnan
- Yonsei University,Severance Hospital , Korea (South) SEO BUM CHO
- Kantou Rousai Hospital , Japan KAORU SUMIDA
- Matsunami General Hospital , Japan TARO TAKEDA
- The Catholic University of Korea Yoeuido St. Mary , Korea (South) CHAWOONG JEON

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 1423 Date 2025-01-27

Discussion

No. of Applicants : 65