A 75-year-old patient presented with complaint of hematuria. Ultrasonography revealed a solid 2-cm mass on right wall of the bladder. Cystoscopy confirmed bladder tumor and patient underwent transurethral resection of bladder tumor. The pathologic diagnosis was pTa, G2 transitional cell carcinoma and carcinoma in situ (WHO 1973). He was offered six weeks of BCG instillation (OncoTICE , Tice Strain, administered intravesically after reconstitution in 50 ml saline). The patient was unable to complete the treatment cycles consecutively due to severe irritative symptoms; hence at the second and fourth week, treatment cycles were cancelled for a period of one week and his symptoms were treated with antibiotics and antispasmodics. Urine cultures were negative for bacterial colonization but pyuria was present at urine analysis. He had no gross hematuria, fever or chills. He was administered five cycles of BCG at full dose, atraumatically, by a staff urologist using a 12Fr hydrophilic Nelaton catheter. There was no external spillage during the administration of BCG. One week after the last instillation the patient reported penile swelling and tenderness, itching at suprapubic areas. Two days later, he presented with a penile lesion and indurated lesions at the suprapubic area. Physical examination demonstrated two areas of painless indurated lesions at the pubic area and shallow ulceration on the penil shaft [Figures 1a and b] and bilateral palpable inguinal lymphadenopathy. He had low-grade fever without chills. He had no history of tuberculosis, diabetes or immunodeficiency. Chest X-ray was unremarkable and computed tomography (CT) of abdomen revealed bilateral inguinal adenopathy (maximal length of diameter 1cm on the left and 1,5 on the right side). Laboratory data showed slight elevation of C-reactive protein and erythrocyte sedimentation rate, and otherwise blood chemistry was normal. Polymerase chain reaction (PCR) for urine tubercle bacilli was negative, and thereafter urine cultures were also negative for mycobacterium.
The patient underwent diagnostic biopsy from the papules of pubic areas and cystoscopy at the same time. Cystoscopy showed several erythematous areas in the bladder and cold-cut biopsy was obtained from these areas. Pathology of the bladder biopsies revealed acute and chronic inflammation with granulomatous changes; there was no evidence of malignancy. The pathologic examination of biopsy samples from endurated pubic lesions demonstrated granulomatous inflammation with caseous necroses [Figure 2] and multinucleated giant cells of Langhans type, which was compatible with BCG-induced granulomatous skin infection.
Intravesical BCG instillation therapy was discontinued and the patient was given a three-drug antitubercular regimen including rifampicin, isoniazid, and pyrazinamide. The total treatment course was six months, with discontinuation of pyrazinamide after two months. Complete resolution of penile, pubic lesions and inguinal adenopathy was achieved at six months of treatment [Figures 1c and d]. Follow-up cystoscopy showed no evidence of tumor recurrence and CT of abdomen and chest X-ray were unremarkable.