Case Presentation: A 78-year-man with a high-grade-T1-urothelial carcinoma status post transurethral resection of the prostate (TURBT), on weekly intravesical-BCG for past 2-months, presented a day following his last instillation with fever, chills and altered mental state. In the ED, he was febrile (102.8), tachypnoeic (42/min) & hypotensive (SBP in 70s). Initial labs showed elevated WBC (27.2) and lactate (7.8). CXR was normal. He was intubated and empirically treated with Piperacillin-Tazobactam. No pathogens were identified on gram-stain, and cultures from urine, blood and sputum returned negative, but he continued to have low-grade-fever. Repeat CXR was suspicious for hospital-acquired-pneumonia, and he was started on Levofloxacin. AFB blood culture ordered at admission came back positive only four weeks later for Mycobacterium-TB-complex in 2/2 sets of collected sample, still pending final identification and sensitivities. He was promptly started on triple anti-TB therapy with isoniazid, rifampicin & ethambutol resulting in gradual resolution of his symptoms. Final blood AFB culture reports returned few months later revealing Mycobacterium bovis sensitive to the anti-tuberculosis medications thus confirming our suspicion.

Discussion: Intravesical instillation of Baccilus-Calmette-Guerin (BCG), a live-attenuated-strain of Mycobacterium bovis, is an established treatment for superficial bladder carcinoma. Although generally well-tolerated, 1 in 15,000 patients can develop life-threatening disseminated BCG infection typically soon after the procedure. This case highlights this potential rare iatrogenic side effect of intravesical BCG treatment and the risk associated with non-treatment of BCG-osis.

Conclusions: Side-effects of intravesical BCG instillation including fever, chills, fatigue are common but BCG-osis, resulting from systemic absorption of Mycobacterium-bovis, is rare and severe, oftentimes requiring intensive-care-unit admission and triple anti-TB-therapy. It is therefore important for clinicians to recognize this possibility as the absence of specific signs-and-symptoms, coupled with the fastidious nature of the mycobacteria, pose a diagnostic-dilemma in the acute-setting.