Bcg

Abstract

Thrombocytopenia, miliary tuberculosis, reactive arthritis and drug overdose: 3 case reports In a case series, three men aged 61-71 years were described of whom, one man developed drug toxicity and thrombocytopenia following an overdose of BCG and the remaining two men developed miliary tuberculosis and reactive arthritis, respectively during BCG treatment [not all indications stated]. Case 1: The 61-year-old man had been receiving an induction therapy with intravesical BCG 120mg [SII ONCO BCG, India]. After the third instillation, he was admitted with dysuria, suprapubic pain and fatigue. An administration of high dose of intravesical BCG (three times higher then normal dose) was noted. Hence, the BCG program was suspended. Routine blood and urinalysis were performed. Elevation of CRP, decrease in white blood cell count and a severe decrease in platelet count was noted. Pre-treatment platelet count was normal. Hematological work-up showed no other cause for this thrombocytopenic condition except high dose BCG toxicity. He initially treated with two units of thrombocyte replacement and as a result his platelet count increased on the same day. No bleeding complication was seen. No more thrombocyte replacement needed and in the second week his platelet count was 170 00 x 10&#179;/L. He was discharged without any complication on the fifteenth day. Case 2: The 61-year-old man was started on an induction therapy with intravesical BCG 120mg [SII ONCO BCG, India]. One month after the completion of BCG therapy, he presented to hospital with fever, cough, weakness, penile mass and vision loss in the left eye. Hence, he was admitted and routine blood, urine and radiological tests were performed. His physical examination was normal except round, firm, well-shaped two penile subcutaneous masses. Penile ultrasonography showed 15 x 5mm and 10 x 6mm anechoic cystic lesions that were located subcutaneously at the ventral side and radix of the penis. In order to evaluate vision loss orbital MRI was carried out. It showed left optic disc involvement and a 3.5mm mass nearby the left optic disc. On chest computed tomography, diffuse micronodules were seen in both the lungs suggesting miliary tuberculosis. Cranial MRI showed multiple lesions in the left parietal lobe, the left frontal lobe, and the right temporal lobe. Simultaneously, the penile lesions were excised, and histopathological examination finally showed a granulomatous inflammation. Transbronchial lung biopsy from pulmonary nodules was also confirmed the systemic granulomatous inflammation. Anti-tuberculosis treatment was immediately started with isoniazid, rifampicin and ethambutol. On the first month follow-up, symptoms were regressed and radiological responses were noted. But his vision loss progressed and nearly 75% vision loss was noted in the left eye. Anti-tuberculosis treatment continued for 12 months. Case 3: The 71-year-old man was receiving intravesical BCG 120mg [SII ONCO BCG, India] treatment due to bladder cancer. After five cycles of BCG, he was admitted with a 1-month history of increasing pain and swelling in his hand, foot and knee joints. These complaints were restricting his life; moreover he was using a walking stick for these complaints. He was previously referred to orthopedics and vascular surgery outpatient clinics, and even underwent right knee arthrocentesis. In view of his medical history and physical examination, reactive arthritis secondary to BCG instillation was suspected. Hence, BCG treatment was stopped. Rheumatology consultation showed left foot metatarsophalangeal, right knee, left hand first, second and third phalanx joint reactive arthritis. Blood analysis showed WBC 10.04 x 10&#179;/mL, sedimentation rate 44 mm/h, CRP was 14.9 g/dL and rheumatoid factor (RF) was <20 IU/mL. He was started on methylprednisolone, naproxen and calcium carbonate plus vitamin D3. On the first week of corrective treatment, he showed a significant recovery. His steroid treatment was continued for six months. He was well and tumour free on two-year follow-up.