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Systemic BCG Treatment Complications in an 81-Year-Old Male with Pneumonitis

An 81-year-old African American male presented to the ER with irritative voiding symptoms, dysuria, and fever. His recent history included BCG intravesical therapy for superficial bladder cancer. He exhibited acute mental status changes and was treated for a urinary tract infection. After extensive evaluation, including CT scans and blood cultures, systemic BCG reactions were considered, leading to treatment for hyperpyrexia and AKI. The patient was stabilized and discharged to rehabilitation after 20 days of hospitalization with a tailored medication regimen.

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Systemic BCG Treatment Complications in an 81-Year-Old Male with Pneumonitis

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  1. Systemic BCG with Pneumonitis By Carrie Fitzgerald Uro 1

  2. Urology consult for patient with irritative symptoms R/O UTI 81 year old African American male, appears younger then stated age • Presents with c/o irritative voiding sxs for 24 hr. daughter noticed diaphoresis acute change MS; dysuria, fever 103 brought pt to ER. • Pt seen by medicine and started on empiric parenteral antibiotic treatment after urine culture obtained • Found out 72 hours later patient was post BCG intravesical treatment, including dysuria and frequency and urology consult obtained PMHx Superficial Bladder Ca sp BCG 6 week induction; maintenance dose 72 hr prior; ho sxs post intraves CaP s/p RRP Dementia HTN Meds : Aricept, Cozaar , Enablex, HCTZ, Norvasc, Colace Soc Hx: Tob 30 pack yr, no ETOH, no illicits FamHx: no GU malignancies Hospital day 3

  3. VS 100.2 82 22 154/86 96% • AAOx2, NAD • CTAB, S1S2 no murmurs • Soft, NT no sp ttp, no CVA tenderness • Uncircumsize. Nl Descended. Foley gravity, urine clear, yellow, no meatal erosion bld. Prostate absent. • WBC 5.4 (13.5/ band % 13 on admit) • H/H 11.4/32 12.9/36.4 on admit • BUN 13 Cr 1.16 (35/2.47 on admission) • AST 93 ALT 94AlkP92 • T bili2.26 D bili1.18 • Sterile pyruria (W 20-50) • CXR Labs and Exam

  4. Assessment: UTI vs BCG side effect vs systemic BCG Hyperpyrexia AKI Hyperbilirubinemia Anemia HTN • Bld/U Tb cx • ID consult • Levaquin, INH • WBC Scan • Abd US • CT scan abd/pel • Renal cyst /abscess drainage Assessment and Plan

  5. Bld Cx : no growth 5 d • Ucx : no growth 24 hrs • Misc Cx : R renal cyst aspirate neg for AFB, aerobes, anaerobe Episodes of fever (Tmax 104.4) and diaphoresis Q8-12 hour Expiratory wheezes; O2 sat80% Rigors Change in MS Results and PE

  6. Assessment Disseminated BCG +/- hypersensitivity rxtn Respiratory distress Hepatitis BCG vsPharm Hyperpyrexia Anemia – AOCD w/folate def Urinary incontinence AKI HTN WBC 9.6 (11/band% 25 hosp day 17) H/H 8.3/24 (7.5/21.9 hosp 17) BUN 21 Cr 1.38 AST 162 ALT 78 AlkP102 T bili3.01 D bili1.93 PSA < 0.01 HepBab/Ag - neg Hospital Day 13

  7. Rifampin 600 mg po Qd • Pyrazinamide 1000 mg po Qd • Isoniazid 300 mg po Qd • Levaquin 250 mg po Qd • Stopped Pyrazinamide on 10/27 started Ethambutol 1600mg po daily • Zosyn 3.375 g x1 • Vancomycin 750 mg x 1 • Rocephin 1g x1 • Azithromycin 500 mg x1 Treatment

  8. Lamm consult • Started Solumedrol 40 mg IVP Q 6 hours hosp day 17 with slow taper • Discharged to rehab hosp day 20 In Addition

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