Miliary tuberculosis induced by intravesical BCG instillation in a patient with bladder carcinoma

An interesting case is presented of a 69 year-old man, ex-smoker, who was admitted to the hospital due to 15 days of weakness, malaise and dry cough and a fever of 39 degrees C. The symptoms had persisted even after administration of broad spectrum antibiotics. The patient had history of urinary bladder carcinoma treated by transurethral resection, followed by repeated instillations of Bacillus Calmette-Guerin (BCG). The symptoms appeared 30 days after the 4th instillation of BCG. Physical examination was unremarkable, but chest X-ray revealed multiple micronodular infiltrations in both lungs. High resolution computed tomography (HRCT) scan of the chest showed a miliary pattern in the lungs. The Mantoux test produced a reaction 11 mm in diameter. The administration of two drug antituberculous treatment resulted in clinical improvement with fever remission of 10 days. Multiple studies have demonstrated that transurethral resection of transitional cell bladder carcinoma followed by intravesical instillation of BCG significantly reduces the recurrence and prolongs disease-free survival. However, BCG immunotherapy can produce local and systemic side effects. Miliary tuberculosis is a rare complication of intravesical instillation of BCG in the treatment of transitional cell carcinoma of the bladder. Appropriate antituberculous treatment is required, and on occasion, the adjunctive use of systemic steroids is useful.