T HAN1, C HAN1, Z THET1
1Department of Nephrology, Central Queensland Hospital and Health Service, Rockhampton, QLD
Background: Tuberculosis vaccine is an effective intravesical immunotherapy for superficial urothelial bladder carcinoma. There are only a few reports of intravesical BCG vaccine associated tuberculosis infection published in the literature.
Case report: A 71 year-old man with a superficial high grade and non-invasive papillary urothelial carcinoma of bladder was treated by a 3 year course of intermittent (18 times in total) intravesical BCG therapy. His other medical co-morbidities included hypertension, dyslipidemia, benign prostatic hypertrophy and diverticular disease. He tolerated the treatment well with only local irritation and his bladder cancer was cured. One and a half year after the last instillation of BCG vaccine, acute kidney injury (AKI) was developed. Prior to AKI, he had had a 4 month history of early morning fever, night sweat and severe weight loss. No malignancy or tuberculosis was found in imaginings, gastroscopy and colonoscopy. His eGFR dropped from 90 to 12. Renal biopsy showed acute granulomatous interstitial nephritis with acid fast bacilli (AFB). Urine culture grew Mycobacterium bovis. His BCG related renal tuberculosis was treated successfully with dual anti-tuberculosis therapy (Isoniazid 300mg daily, Rifampicin 600mg daiy) for a year. Three monthly urine AFB results following the treatment remain negative. His acute kidney injury also recovered and his latest eGFR was 41.
Conclusion: Although the intravesical instillation of BCG therapy is considered safe and effective, clinicians should be suspicious of renal tuberculosis when a patient has an acute kidney injury even BCG immunotherapy was given a while ago in immunocompetent patient.