Jacobs Journal of Clinical Case Reports

Acute Diffuse Alveolar Hemorrhage following Intravesical Bacille Calmette-Guérin Immunotherapy for Superficial Bladder Cancer

*Elisa Antonielli
Department Of Case Reports, Italy

*Corresponding Author:
Elisa Antonielli
Department Of Case Reports, Italy
Email:antonielli83@gmail.com

Published on: 2015-01-30

Abstract

We report a case of a 80-year-old man who presented to our emergency department for high fever (39°C), hematuria and dyspnea four hours after intravesicaladministration of Calmette-Guérin bacille (BCG) for a superficial bladder cancer. The patient already underwent two cycles of instillation. He developed hypoxemic respiratory failure with diffuse alveolitis at chest CT scan. Leukocyte count was 2.93 x 109 /L, liver function test revealed aspartate aminotransferase 189U/L (15-37 U/L) and alanine aminotransferase 113 U/L (30-65 U/L). Search for Legionella and pneumococcal urinary antigen and sputum staining for Mycobacterium Tubercolosis were negative. A bronchoscopy revealed diffuse alveolar hemorrhage. The analysis of the bronchoalveolar lavage (BAL) fluid was negative for Mycobacterial species, pneumocystis jirovecii, and other bacterial and viral infection. The nasopharingeal swab for H1N1 was negative as well as results of galactomannan in serum and BAL. Empiric antibiotic treatment was started with no benefits. There was a rapid and significant clinical and radiological improvement with pulsed bolus of steroids and i.v. Immunoglobulins. A control of the computed tomography of the chest revealed multiple ground-glass opacities on both lung fields. Search for autoantibodies (i.e. ANCA, GBM) turned negative as well as BAL cytology. We supposed that a diagnosis of hypersensitivity interstitial pneumonitis with haemorrhagic alveolitis was the most fitting with the clinical picture. In literature there are few reports on hypersensitivity pneumonitis (HP) following intravesical instillation of BCG and none with haemorrhagic alveolitis. HP is explained by a hypersensitivity phenomenon following, usually, traumatic instillation of BCG. Hypersensitivity pneumonitis (HP) is a rare immunologically mediated lung disease caused by repeated exposition of organic antigens and should be considered in patients with acute respiratory symptoms with onset soon after immunotherapy with BCG.

Keywords

Acute Diffuse Alveolar Hemorrhage; Bacille Calmette-Guérin; Superficial Bladder Cancer; Hypersensitivity Pneumonitis

Introduction

Hypersensitivity pneumonitis (HP) is an immunologically mediated lung disease caused by repeated exposition to organic antigens [1,2]. Among many other and more common etiologies, intravesicaladministration of Bacille Calmette-Guérin (BCG) has been rarely described as a cause of HP [3-6]. Moreover, HP rarely is so grave to cause widespread damage of the alveolocapillary membrane, an anatomical-clinical condition known as diffuse alveolar haemorrhage (DAH). DAH is a very severe syndrome that is burdened by high mortality despite aggressive treatment [7], and nowadays no cases of DAH fol-lowing intravesical BCG administration have been reported in medical literature. Herein, we report the first case of HP associated with DAH caused by intravesical BCG administration for the treatment of superficial bladder cancer.