title: Fever of unknown origin and pancytopenia caused by culture-proven delayed onset disseminated bacillus Calmette-Guerin (BCG) infection after intravesical instillation.
abstract: A 78-year-old man was diagnosed with bladder carcinoma in situ and was successfully treated with intravesical bacillus Calmette-Guérin (BCG) instillations. At 6 months after the last dose, he developed fever, weight loss and malaise. He had an extensive negative workup at an outside hospital and was treated empirically with ciprofloxacin for 2 weeks. The fever resolved but returned months later and he was readmitted with pancytopenia, elevated alkaline phosphatase and ground glass opacities on the chest CT. Bone marrow and liver biopsies showed non-caseating granulomas and were negative for acid-fast bacillus (AFB) and fungal stains. Mycobacterium tuberculosis complex PCR of the bone marrow was negative. Owing to the high clinical suspicion of disseminated BCG infection, the patient was treated empirically. After 9 weeks of incubation, the bone marrow AFB culture grew Mycobacterium bovis. Within 2 months of treatment his symptoms resolved and his laboratory results normalised.
authors.affiliation: Department of Pulmonary and Critical care Medicine, Cooper University Hospital, Camden, New Jersey, USA. pedrodammert@hotmail.com
authors.forename: Pedro
authors.initials: P
authors.lastname: Dammert
authors.forename: Ziad
authors.initials: Z
authors.lastname: Boujaoude
authors.forename: William
authors.initials: W
authors.lastname: Rafferty
authors.forename: Jonathan
authors.initials: J
authors.lastname: Kass
mesh_terms: D000283:Administration, Intravesical; D000368:Aged; D000995:Antitubercular Agents / Q000627:therapeutic use; D001500:BCG Vaccine / Q000008:administration & dosage / Q000009:adverse effects*; D001853:Bone Marrow / Q000382:microbiology; D003937:Diagnosis, Differential; D005335:Fever of Unknown Origin / Q000209:etiology*; D006801:Humans; D008297:Male; D009163:Mycobacterium bovis / Q000302:isolation & purification*; D010198:Pancytopenia / Q000209:etiology*; D016133:Polymerase Chain Reaction; D014057:Tomography, X-Ray Computed; D014376:Tuberculosis / Q000139:chemically induced* / Q000188:drug therapy; D001749:Urinary Bladder Neoplasms / Q000188:drug therapy
chemical_list: D000995:Antitubercular Agents; D001500:BCG Vaccine