BCG

BCG Reactions 1704, p65 - 2 Jun 2018 weakness and fever. Physical examination revealed no abnormalities apart from tachycardia and fever. Blood tests revealed an elevated CRP and leucocytosis. A CT scan revealed a fluid collection on the left dorsolateral side of the bovine Mycotic aneurysm of the abdominal aorta: case aorta tube graft extending into the left psoas muscle. The CT- report guided drainage was done and the culture obtained revealed A 73-year-old man developed mycotic aneurysm of the mycobacterium in the aspirated fluid. It was not clear whether abdominal aorta during treatment with BCG [Bacillus the collection resulted from paradoxical abscess formation or Calmette-Guerin] for early stage transitional cell bladder due to active Mycobacterium bovis infection during anti- cancer. tuberculosis therapy. He was treated for both paradoxical The man with severe fatigue, weight loss, lower back pain abscess formation and active Mycobacterium bovis infection. was examined by internal medicine department. He had His therapy was changed to moxifloxacin, ethambutol and history of early stage transitional cell bladder cancer with rifampicin. His paradoxical abscess formation was treated with invasion of the sub-mucosa in 2012. In 2013, he was drainage and dexamethasone. His condition improved. A diagnosed with recurrence of bladder cancer. He received follow-up CT scan revealed a significant decrease of the adjuvant treatment with intravesical BCG solution once weekly collection. Hence, he was discharged. for 6 weeks [dose not stated]. Two years later, on examination Author comment: "In this writing, we present a case of for the above mentioned symptoms, pain on palpation cranial mycotic abdominal aneurysm caused by M. bovis infection to the left iliac crest and peripheral oedema of the lower related to prior intravesical BCG instillation". extremities were noted. Since, occult metastatic disease was a possible reason for the symptoms, a PET scan was done, which Roeke T, et al. A mycotic aneurysm of the abdominal aorta caused by revealed pathologic activity of the abdominal aorta and left Mycobacterium bovis after intravesical instillation with bacillus Calmette-Guerin. Journal of Vascular Surgery Cases and Innovative Techniques 4: 122-125, No. 2, iliopsoas muscle. A CT scan of thoracoabdominal revealed a Jun 2018. Available from: URL: http://doi.org/10.1016/j.jvscit.2018.01.008 - pseudoaneurysm of the abdominal aorta and surrounding Netherlands 803323074 infiltration. These finding where suggestive of mycotic aneurysm [duration of treatment to reaction onset not stated]. Since, he did not experience any septic episodes, and pointers of infection stayed only mildly raised, it was decided to implement elective open aorta re-constructive surgery in the short period of time. The man underwent surgery in February 2016. The aneurysm started just caudal to the renal arteries. He was planned for a neoaortoiliac system bypass. However, due to limited infected area, reconstructive repair was done with a bovine (pericardial) tube graft. The infected aneurysmal segment was removed. A group of softened and infected mushy tissue was observed on the left side of the aneurysm. A culture and biopsy sample from the surrounding tissue and aorta were collected. All tissue presenting signs of infection were removed. A resorbable sponge soaked with gentamicin was left behind in the cavity post removal of the aneurysm and surrounding the infected tissue. Subsequently, rifampicin was directly applied to the cavity, and the graft was sutured and protected with a greater omentum wrap plasty. Three samples of para-aortic tissue were cultured. One sample showed Mycobacterium bovis. Pathologic evaluation revealed extensive granulomatous and necrotising inflammation of the aorta. However, the histologic Ziehl-Neelsen staining used to recognise acid-fast organisms such as Mycobacterium bovis was found to be negative. DNA examination revealed that the cultured strain of Mycobacterium bovis was identical to the one used for the BCG solution, which was administered in 2013. This BCG solution was the source of the Mycobacterium bovis infection causing mycotic aortic aneurysm. Initially, the exact resistance-related features of the mycobacterium were not known. Hence, initially he was treated with ethambutol, pyrazinamide, isoniazid, and rifampicin. The moment it became clear that Mycobacterium bovis had produced the infection, treatment with pyrazinamide was discontinued. Postoperatively, he experienced severe inflammatory response syndrome (of an unknown aetiology) and was hospitalised to the ICU. Additionally, he developed acute on chronic renal insufficiency (of an unknown aetiology), for which haemodialysis was performed. His postoperative course was complicated by accumulation of chylous ascites and paralytic ileus (of an unknown aetiology). He was treated with a combination of total parenteral nutrition, paracentesis and octreotide for chylous ascites. Gradually, his condition improved and haemodialysis was discontinued. Chylous ascites production substantially diminished, and the ileus resolved. He was moved to the general surgery ward. Subsequently, his condition improved and he was moved to a rehabilitation center 2 months post surgery. He continued receiving ethambutol, isoniazid and rifampicin. Three months post discharge, he was re-admitted with malaise, generalised 0114-9954/18/1704-0001/$14.95 Adis © 2018 Springer International Publishing AG. All rights reserved Reactions 2 Jun 2018 No. 1704 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Reactions Weekly Springer Journals

BCG

Reactions Weekly , Volume 1704 (1) – Jun 2, 2018
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Publisher
Springer International Publishing
Copyright
Copyright © 2018 by Springer International Publishing AG, part of Springer Nature
Subject
Medicine & Public Health; Drug Safety and Pharmacovigilance; Pharmacology/Toxicology
ISSN
0114-9954
eISSN
1179-2051
D.O.I.
10.1007/s40278-018-46708-x
Publisher site
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Abstract

Reactions 1704, p65 - 2 Jun 2018 weakness and fever. Physical examination revealed no abnormalities apart from tachycardia and fever. Blood tests revealed an elevated CRP and leucocytosis. A CT scan revealed a fluid collection on the left dorsolateral side of the bovine Mycotic aneurysm of the abdominal aorta: case aorta tube graft extending into the left psoas muscle. The CT- report guided drainage was done and the culture obtained revealed A 73-year-old man developed mycotic aneurysm of the mycobacterium in the aspirated fluid. It was not clear whether abdominal aorta during treatment with BCG [Bacillus the collection resulted from paradoxical abscess formation or Calmette-Guerin] for early stage transitional cell bladder due to active Mycobacterium bovis infection during anti- cancer. tuberculosis therapy. He was treated for both paradoxical The man with severe fatigue, weight loss, lower back pain abscess formation and active Mycobacterium bovis infection. was examined by internal medicine department. He had His therapy was changed to moxifloxacin, ethambutol and history of early stage transitional cell bladder cancer with rifampicin. His paradoxical abscess formation was treated with invasion of the sub-mucosa in 2012. In 2013, he was drainage and dexamethasone. His condition improved. A diagnosed with recurrence of bladder cancer. He received follow-up CT scan revealed a significant decrease of the adjuvant treatment with intravesical BCG solution once weekly collection. Hence, he was discharged. for 6 weeks [dose not stated]. Two years later, on examination Author comment: "In this writing, we present a case of for the above mentioned symptoms, pain on palpation cranial mycotic abdominal aneurysm caused by M. bovis infection to the left iliac crest and peripheral oedema of the lower related to prior intravesical BCG instillation". extremities were noted. Since, occult metastatic disease was a possible reason for the symptoms, a PET scan was done, which Roeke T, et al. A mycotic aneurysm of the abdominal aorta caused by revealed pathologic activity of the abdominal aorta and left Mycobacterium bovis after intravesical instillation with bacillus Calmette-Guerin. Journal of Vascular Surgery Cases and Innovative Techniques 4: 122-125, No. 2, iliopsoas muscle. A CT scan of thoracoabdominal revealed a Jun 2018. Available from: URL: http://doi.org/10.1016/j.jvscit.2018.01.008 - pseudoaneurysm of the abdominal aorta and surrounding Netherlands 803323074 infiltration. These finding where suggestive of mycotic aneurysm [duration of treatment to reaction onset not stated]. Since, he did not experience any septic episodes, and pointers of infection stayed only mildly raised, it was decided to implement elective open aorta re-constructive surgery in the short period of time. The man underwent surgery in February 2016. The aneurysm started just caudal to the renal arteries. He was planned for a neoaortoiliac system bypass. However, due to limited infected area, reconstructive repair was done with a bovine (pericardial) tube graft. The infected aneurysmal segment was removed. A group of softened and infected mushy tissue was observed on the left side of the aneurysm. A culture and biopsy sample from the surrounding tissue and aorta were collected. All tissue presenting signs of infection were removed. A resorbable sponge soaked with gentamicin was left behind in the cavity post removal of the aneurysm and surrounding the infected tissue. Subsequently, rifampicin was directly applied to the cavity, and the graft was sutured and protected with a greater omentum wrap plasty. Three samples of para-aortic tissue were cultured. One sample showed Mycobacterium bovis. Pathologic evaluation revealed extensive granulomatous and necrotising inflammation of the aorta. However, the histologic Ziehl-Neelsen staining used to recognise acid-fast organisms such as Mycobacterium bovis was found to be negative. DNA examination revealed that the cultured strain of Mycobacterium bovis was identical to the one used for the BCG solution, which was administered in 2013. This BCG solution was the source of the Mycobacterium bovis infection causing mycotic aortic aneurysm. Initially, the exact resistance-related features of the mycobacterium were not known. Hence, initially he was treated with ethambutol, pyrazinamide, isoniazid, and rifampicin. The moment it became clear that Mycobacterium bovis had produced the infection, treatment with pyrazinamide was discontinued. Postoperatively, he experienced severe inflammatory response syndrome (of an unknown aetiology) and was hospitalised to the ICU. Additionally, he developed acute on chronic renal insufficiency (of an unknown aetiology), for which haemodialysis was performed. His postoperative course was complicated by accumulation of chylous ascites and paralytic ileus (of an unknown aetiology). He was treated with a combination of total parenteral nutrition, paracentesis and octreotide for chylous ascites. Gradually, his condition improved and haemodialysis was discontinued. Chylous ascites production substantially diminished, and the ileus resolved. He was moved to the general surgery ward. Subsequently, his condition improved and he was moved to a rehabilitation center 2 months post surgery. He continued receiving ethambutol, isoniazid and rifampicin. Three months post discharge, he was re-admitted with malaise, generalised 0114-9954/18/1704-0001/$14.95 Adis © 2018 Springer International Publishing AG. All rights reserved Reactions 2 Jun 2018 No. 1704

Journal

Reactions WeeklySpringer Journals

Published: Jun 2, 2018

References

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