Intravesical administration of Bacillus Calmette-Guerin (BCG), a live attenuated strain of Mycobacterium bovis, is used as an adjunctive therapy for superficial bladder cancer. Although mostly well tolerated, disseminated infections can occur rarely. We describe a case of Mycobacterial vertebral osteomyelitis (Pott’s disease) following BCG immunotherapy that was treated with anti-tubercular therapy.
An 89-year-old-male with a history of bladder cancer presented with the chief complaint of worsening lower back pain of one month duration. He also had low grade fevers and night sweats with anorexia. He did not have any significant past medical, surgical or travel history. On examination he was afebrile with normal vitals. His back exam revealed tenderness on palpation over the L5 spinous process. Rest of the physical examination including a thorough neurological exam was within normal limits. A Magnetic Resonance Imaging of the lumbosacral region revealed discitis and osteomyelitis at L5-S1 with extension into the paraspinal soft tissues, but without obvious extraspinal abscess. A CT guided biopsy was positive for Acid Fast Bacilli (AFB). AFB culture grew Mycobacterium tuberculosis complex (M. bovis) which was confirmed with DNA probe testing. He had received of BCG immunotherapy (but discontinued after 2 cycles due to intolerance) for high grade superficial bladder cancer 20 months prior to the presentation. He was started on a combined regimen including isoniazid, rifampin, ethambutol and pyrazinamide which was later changed to isoniazid and rifampin after 2 months.
Vertebral osteomyelitis is a rare complication of disseminated BCG infection with only a handful of cases reported so far. Although rare, clinicians need to be aware of the possibility of disseminated infection such as vertebral osteomyelitis by M. bovis BCG in the appropriate setting of relapsing fever, night sweats, and progressive back pain in a patient with recent BCG therapy. Treatment involves prolonged (often >1 year) regimen of combination anti-tubercular drugs. Patients who develop infectious complications severe enough to require antituberculous therapy should generally not receive further BCG bladder instillations.
To cite this abstract:Pathak R, Giri S, Siwakoti K, Ghimire S, Poudel DR, Khanal R, Karmacharya P. Pott’s Disease Following Intravesical Bcg Therapy. Abstract published at Hospital Medicine 2016, March 6-9, San Diego, Calif. Abstract 732. Journal of Hospital Medicine. 2016; 11 (suppl 1). https://www.shmabstracts.com/abstract/potts-disease-following-intravesical-bcg-therapy/. Accessed April 5, 2020.