An 88-year-old male patient was diagnosed with superficial transitional cell carcinoma of the bladder (T1). He underwent multiple sessions of TURBT followed by weekly intravesical BCG therapy in June 2013. Immediately following his fourth BCG session, he developed fever, rigors, respiratory distress, episodes of syncope and confusion, raised inflammatory markers, and disseminated intravascular coagulation (DIC) shortly after BCG instillation. Brain computerized tomography (CT) scan and Holter monitor were normal. An electroencephalogram (EEG) demonstrated features suggestive of moderate global cerebral dysfunction. Three days later, he developed fever of 39.5  C associated with chills and rigors and received empiric intravenous antibiotics. His course was complicated by gross hematuria. His hemoglobin level (Hb) dropped from 13.8 to 7.6 g/dL. Blood and cerebrospinal fluid (CSF) culture reports were negative; CSF protein level was 0.35 g/L, white blood cell (WBC) count was 1 cell/microL, and glucose was 7.1 mmol/L. The polymerase chain reaction for Mycobacterium tuberculosis in sputum and CSF was also negative. Laboratory examination revealed pancytopenia with WBCs 1.8 x 109 cell/L, Hb 10.3 g/dL, and platelets 39 x 109/L. There was evidence of DIC with elevated prothrombin time 18.7, partial thromboplastin time 47, low fibrinogen 1.1 g/L (normal range 2.0-4.0 g/L), a positive D-dimer test, and serum albumin 28 g/L. Levels of bilirubin, alanine aminotransferase, and alkaline phosphatase (64 micromol/L, 320 IU/L, and 244 IU/L, respectively) were elevated. Lactate dehydrogenase level was high (1128 IU/L), and CA-125 was 88 U/mL. CT scan of the chest and abdomen was reported to show bilateral basal ground glass opacities and air space disease associated with bilateral mild pleural effusion. A ground glass nodule was seen in the (R) upper lobe (Fig. 1). Bone marrow aspirates and trephine biopsy showed multiple small granulomas (Figs. 2 and 3). Liver biopsy, on the other hand, could not be done because of the DIC. Sputum, bone marrow, CSF, and urine smear test results and cultures for mycobacteria were negative.
He received isoniazid 300 mg, rifampicin 600 mg, and ethambutol 1.2 g, together with prednisolone 60 mg once daily. One month following anti-Tuberculosis (TB) treatment, he developed skin rash and eosinophilia. Skin biopsy showed spongiotic and interface dermatitis with few eosinophils consistent with drug eruption. Treatment of TB was adjusted. He continued to improve gradually with defervescence and normalization of his blood counts. His DIC was reversed, and C-reactive protein dropped from 98 mg/L to 8 mg/L. CA-125 decreased from 88 to 16 U/L. His latest blood tests showed Hb 12.9 g/dL, WBC 9 x 109 cell/L, platelets 364 x 109/L, alanine aminotransferase 13 IU/L, alkaline phosphatase 72 IU/L, and albumin 39 g/L. The patient was doing well at the time of preparation of this manuscript.
CT scan of chest showing bilateral ground glass and air space opacities and a ground glass nodule seen in the right upper lobe.