Granulomatous hepatitis, choroiditis and aortoduodenal fistula complicating intravesical Bacillus Calmette-Guérin therapy: Case report

We report a case of disseminated, post-treatment BCG infection that initially presented with granulomatous hepatitis and choroiditis. After successful anti-mycobacterial therapy and resolution of the hepatic and ocular abnormalities, the patient developed an acute upper gastrointestinal hemorrhage from an aortoduodenal fistula that required emergency surgery. The resection specimen revealed multifocal, non-caseating granulomas, indicating mycobacterial involvement.This case highlights the varied end organ complications of disseminated BCG infection, and the need for vigilance even in immuno-competent patients with a history of intravesical BCG treatment.Bacillus Calmette-Guérin (BCG) is a live, attenuated strain of the bovine tuberculosis bacillus, Mycobacterium bovis. Immunotherapy of neoplastic disease with BCG was developed in the 1960s and has been used for multiple neoplasms including malignant melanoma and acute lymphoblastic leukemia. In 1976, Morales et al. were the first to use intravesical BCG instillation to treat superficial bladder cancer [1]. Since then, BCG therapy has become the treatment of choice for early stage transitional cell carcinoma of the bladder, with response rates ranging from 60%-94% - higher than any chemotherapeutic agent [2].Although the virulence of attenuated BCG is low, serious and potentially life-threatening infections can occur even in the immunocompetent host. Adverse effects of BCG immunotherapy develop in 3-5% of patients [3]. They include local complications such as bacterial cystitis, bladder contractures, granulomatous prostatitis, epididymitis, orchitis, and systemic reactions such as fever, malaise, hepatitis, and pneumonitis. Disseminated BCG infections presenting as pneumonitis or granulomatous hepatitis, are rare: in the largest retrospective study reported to date, dissemination occurred in 0.7% of over 2,000 patients [4]. Ocular BCG manifestations include uveitis, endophthalmitis, and rarely choroiditis [5,6]. The