Case Presentation: The patient is an 80-year-old female with a history of urothelial cancer of the bladder status post transurethral resection and intravesical Bacillus Calmette-Guerin (BCG) treatment, gastrointestinal stromal tumor status post partial gastrectomy, and atrial fibrillation. Two years after completion of intravesical BCG treatment, surveillance computed tomography (CT) imaging showed a penetrating ulcer of the infrarenal abdominal aorta. The CT also noted surrounding soft tissue stranding and possible small mycotic abscess vs centrally necrotic lymph node. A CT abdominal aortic aneurysm protocol demonstrated similar findings, recommending correlation with symptoms of bacteremia since mycotic pseudoaneurysm may present similarly. When she was admitted for endovascular repair, her temperature was 37.2C, heart rate 66 beats per minute, blood pressure 125/58 mmHg, respiratory rate 16/min, and oxygen saturation 98% on room air. Labs were notable for WBC 6.2 cells/µL, ESR 83 mm/hour and CRP 5.47 mg/dL. She underwent uncomplicated endovascular repair; no operative cultures were taken, though blood cultures from this admission were negative. Three months after repair, she presented with bilateral lower extremity weakness and was found to have L3-L4 osteomyelitis, an epidural abscess, and bilateral psoas abscesses on magnetic resonance imaging (MRI) of the spine. The left psoas abscess was aspirated by Interventional Radiology. As the patient preferred to avoid invasive surgeries, she was discharged on broad spectrum antibiotics (vancomycin and cefepime) with pending cultures and without source control being achieved. A week later, the culture from the psoas abscess grew Mycobacterium tuberculosis complex (MTBC). She was readmitted for initiation of MTBC treatment with ethambutol, pyrazinamide, isoniazid, and rifabutin (RIPE). Infectious Diseases was consulted and determined the infection was in fact likely related to the BCG installation several years prior, given that it is not possible to distinguish M. bovis from M. tuberculosis on the broad-range PCR that was performed. Treatment with modified RIPE therapy (the above minus pyrazinamide) was continued. Two months later, she presented with nausea, weakness, decreased appetite, and ten-pound weight loss. She was found to have recurrent psoas abscesses requiring drain placement; abscess cultures were negative at that time. Currently, she is under home hospice care due to multiple medical conditions that do not have available treatments in line with her wishes.
Discussion: Although there have been documented cases of disseminated mycobacterial infections following BCG installation for urothelial cancer, these typically occur in patients who are immunosuppressed (1, 2). This patient was not on any immunosuppressive therapy when she presented with the aortic ulcer, nor when she underwent intravesical BCG treatment. This case demonstrates the importance of maintaining a high index of suspicion for disseminated mycobacterial infection in patients who have been treated with intravesical BCG, even if they are not immunosuppressed and even if they have negative blood cultures. Given that hospitalists are often the first to assess patients presenting with disseminated infections, it is crucial for us to be aware of this rare complication of BCG therapy.
Conclusions: Hospitalists should consider disseminated mycobacterial infection in patients who have a history of receiving intravesical BCG treatment for bladder cancer.