[Miliary Pulmonary Tuberculosis After Intravesical BCG Instillation in a Patient with High-Grade Bladder Cancer]. / Intravezikal BCG Uygulamasi Sonrasi Olusan Miliyer Akciger Tüberkülozu Olgusu.

Intravesical administration of Bacillus Calmette-Guerin (BCG) vaccine is used in the treatment of superficial bladder cancer. In clinical practice, intravesical BCG immunotherapy after transurethral tumor resection is a highly effective treatment option in preventing tumor recurrence and progression in medium and high risk superficial bladder tumors. Since patients are given live tuberculosis (TB) bacillus, serious side effects such as pneumonia, sepsis and even death can be seen. Lung involvement occurs in less than 1% of patients and most commonly presents as interstitial pneumonia or miliary TB. Miliary TB is difficult to diagnose and is usually based on high clinical suspicion, as Mycobacterium bovis is not isolated in most cases. Treatment is not completely standardized. However, in severe cases, a combination of antituberculosis drugs and corticosteroids is recommended. In this report, a case of miliary tuberculosis, a very rare complication after instillation of BCG into the bladder in a patient with a diagnosis of superficial bladder cancer, was presented. A 73-year-old male patient diagnosed with bladder tumor underwent transurethral resection of bladder tumor, and then weekly intravesical injection of BCG-MEDAC for six weeks had no adverse effects. Three weeks of intravesical BCG supplementation was planned for the patient who had no signs of recurrence when checked three months later by cystoscopy. Two hours after the first dose, the patient, who applied to the emergency department with the complaint of chills and shivering, was hospitalized for further follow-up and treatment. Afterwards, repeat cultures were taken from the patient whose fever continued on the seventh day of treatment with broad-spectrum antibiotics (meropenem and teicoplanin). In addition, when abdominal and thorax computed tomography (CT) were performed, multiple miliary nodular lesions were detected in both lungs and were evaluated in favor of miliary TB. With these findings, the patient was started on miliary TB therapy [isoniazid (INH), rifampicin (RIF), ethambutol (EMB) and streptomycin (STM)] targeting Mycobacterium bovis, since it was an infection that developed after BCG injection. In the third week of the treatment, the patient's fever was under control, and he was discharged on the 25th day of his hospitalization because of significant improvement in infection markers [C-reactive protein(CRP)-procalcitonin]. At the end of two months, there was clear regression of pulmonary abnormalities on control thorax CT. In conclusion, miliary TB developing after intravesical BCG instillation is a very rare condition, the cause of which is not fully understood, the etiology of fever can be easily missed, and the diagnosis is difficult. In addition, this case is presented to draw attention to a critical disease that requires long treatment and follow-up and requires attention.

Analysis of Clinical Features and Risk Factors in Pregnant Women With Miliary Pulmonary Tuberculosis After In Vitro Fertilization Embryo Transfer.

Purpose: Miliary pulmonary tuberculosis (TB) among pregnant women after in vitro fertilization embryo transfer (IVF-ET) causes poor outcomes but is rarely reported. This study analyzed the clinical characteristics and risk factors of these patients to provide hints for further studies. Method: The demographic characteristics, clinical manifestations, radiologic features, treatment, and outcomes of six patients diagnosed from May 2012 to August 2021 in Xiangya Hospital and 69 patients that were reported in English or Chinese literature from January 1980 to August 2021 were retrospectively analyzed. Continuous variables were compared between groups by t-test or Mann-Whitney U test, and categorical variables were compared between groups by chi-square test or Fisher exact test. Univariate and multiple logistic regression analyses were used to determine the predictors of respiratory failure. Results: A total of 75 patients were included. The average age of patients was about 30 years. All patients had tubal obstruction; 5 of them were diagnosed with pelvic TB before. Thirteen cases had a history of pulmonary or extrapulmonary TB, six out of them without any antituberculosis treatment history. All patients were in their first or second trimester during the onset of symptoms. The average interval between onset of symptoms and radiologic examination was about 21 days. The most common abnormalities on chest computed tomography scan were multiple nodules, pulmonary infiltrate, and consolidation. Merely 10 patients obtained bacteriological diagnosis by Mycobacterium tuberculosis culture or polymerase chain reaction test. The other patients were clinically diagnosed. All the patients received antituberculosis treatment. Although 44% of patients had fatal complications, all cases were cured or improved after antituberculosis treatment. Unfortunately, only eight fetuses survived (10.6%). The most frequent and severe complication was type I respiratory failure (20%). Patients with expectoration, dyspnea, coarse breath sounds, ground-glass opacity, and pulmonary infiltrate or consolidation were more likely to have respiratory failure (P < 0.05). Ground-glass opacity (OR = 48.545, 95% CI = 2.366-995.974, P = 0.012) and pulmonary infiltrate or consolidation (OR = 19.943, 95% CI = 2.159-184.213, P = 0.008) were independent predictors for respiratory failure. Conclusion: Tube infertility with underscreened or untreated TB is a risk factor for miliary TB during pregnancy after IVF-ET. Ground-glass opacity and pulmonary infiltrate or consolidation are predictors of respiratory failure. We demonstrate risk factors for incidence and complications to supply clues for future intervention and improve patient prognosis.

Case Report: Development of Miliary Pulmonary Tuberculosis in a Patient with Peritoneal Tuberculosis after COVID-19 Upper Respiratory Tract Infection.

We report a 29-year-old patient who presented with coronavirus disease 2019 (COVID-19) upper respiratory tract infection in addition to clinical, laboratory, and radiological findings highly suggestive of peritoneal tuberculosis (TB) without pulmonary involvement. Two weeks after the resolution of COVID-19 infection, he presented with shortness of breath and oxygen desaturation requiring intubation and admission to the intensive care unit. The workup confirmed miliary pulmonary TB. The patient subsequently improved on antitubercular treatment. We discuss the possible contribution of COVID-19 infection to the rapid progression of TB infection to involve the lung in a miliary pattern, and how the coexistence of the two diseases might have led to a worse outcome.

Use of steroids to treat anti-tumor necrosis factor α induced tuberculosis-associated immune reconstitution inflammatory syndrome: Case report and literature review.

INTRODUCTION: Individuals with tuberculosis (TB) who are being treated with anti-tumor necrosis factor α (anti-TNFα) for coexisting conditions may experience unexpected exacerbations of TB after the initiation of antituberculous therapy, so-called anti-TNFα-induced TB-immune reconstitution inflammatory syndrome (anti-TNFα-induced TB-IRIS). Anti-TNFα-induced TB-IRIS is often treated empirically with corticosteroids; however, the evidence of the effectiveness of corticosteroids is lacking and the management can be a challenge. PATIENT CONCERNS: A 32-year-old man on long-term infliximab therapy for Crohn disease visited a clinic complaining of persistent fever and cough that had started 1 week previously. His most recent infliximab injection had been administered 14 days before the visit. A chest X-ray revealed a left pleural effusion, and he was admitted to a local hospital. DIAGNOSIS: A chest computed tomography (CT) scan revealed miliary pulmonary nodules; acid-fast bacilli were found in a sputum smear and a urine sediment sample; and polymerase chain reaction confirmed the presence of Mycobacterium tuberculosis in both his sputum and the pleural effusion. He was diagnosed with miliary TB. INTERVENTIONS: Antituberculous therapy was started and he was transferred to our hospital for further management. His symptoms initially improved after the initiation of antituberculous therapy, but 2 weeks later, his symptoms recurred and shadows on chest X-ray worsened. A repeat chest CT scan revealed enlarged miliary pulmonary nodules, extensive ground-glass opacities, and an increased volume of his pleural effusion. This paradoxical exacerbation was diagnosed as TB-IRIS associated with infliximab. A moderate-dose of systemic corticosteroid was initiated [prednisolone 25 mg/day (0.5 mg/kg/day)]. OUTCOMES: After starting corticosteroid treatment, his radiological findings improved immediately, and his fever and cough disappeared within a few days. After discharge, prednisolone was tapered off over the course of 10 weeks, and he completed a 9-month course of antituberculous therapy uneventfully. He had not restarted infliximab at his most recent follow-up 14 months later. CONCLUSION: We successfully managed a patient with anti-TNFα-induced TB-IRIS using moderate-dose corticosteroids. Due to the limited evidence currently available, physicians should consider the necessity, dosage, and duration of corticosteroids for each case of anti-TNFα-induced TB-IRIS on an individual patient-by-patient basis.

Prevalence and risk factors of paradoxical tuberculosis associated immune reconstitution inflammatory syndrome among HIV-infected patients in Beijing, China.

BACKGROUND: In this study, we aimed to describe the prevalence, clinical presentation and risk factors of paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) cases in China. METHODS: We performed a descriptive analysis of demographic and clinical data of HIV/TB coinfected patients receiving ART at Beijing Ditan Hospital between January 2014 and October 2018. RESULTS: Of 199 patients included, 45 (22.6%) developed paradoxical TB-IRIS, and 19 (9.5%) TB-IRIS cases presented miliary TB. The pre-ART CD4 count lower than 50 cells/mm3 was found to be significantly associated with development of TB-IRIS. Similarly, patients with higher than 4-fold increase in CD4 cell count after antiretroviral therapy (ART) had significantly higher odds of having TB-IRIS. When patients aged 25-44 years were utilized as the control group, youths (< 25 years old) were more likely to have miliary TB. No significant difference was observed in the intervals from initiation of ART to IRIS presentation between miliary and non-miliary group. CONCLUSIONS: In conclusion, our data demonstrate that approximate one quarter of patients coinfected with TB and HIV develop paradoxical TB-IRIS after initial of ART therapy in China. Lower baseline CD4 count and rapid increase in CD4 count are the major risk factors associated with the occurrence of paradoxical TB-IRIS.

Disseminated Tuberculosis with Cholecystitis in a Patient after Cord Blood Transplantation.

The incidence of an active tuberculosis infection after allogeneic hematopoietic cell transplantation is high. We herein report the case of a patient with acute myeloid leukemia after cord blood transplantation (CBT). On day 36 after CBT, the patient developed fever, and a computed tomography scan on day 36 showed mild thickening of the wall of the gallbladder. Subsequently, a sputum specimen and a blood culture returned positive for the growth of Mycobacterium tuberculosis. After 2 months of administering combination therapy, both the symptoms and gallbladder findings improved. We therefore describe a case of disseminated tuberculosis with the gallbladder mimicking acute cholecystitis in a CBT recipient.

Infección diseminada por Mycobacterium scrofulaceum en paciente en tratamiento con golimumab / Disseminated Mycobacterium scrofulaceum infection in a patient in treatment with golimumab

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Tuberculosis under anti-TNF therapy: case series of a center (reporting the experience from the period 2006-2019).

Patients with inflammatory rheumatic diseases refractory to conventional disease modifying antirheumatic drugs (DMARDs)have been treated with biologics for the last two decades. It is also known that patients under biotechnological therapy present a higher risk of developing Tuberculosis (TB).Portugal has now a TB incidence classified as low. National recommendations advise on latent TB screening before the beginning of the biological therapy. This screening consists in the detection of risk factors and/or signs and symptoms of latent TB through clinical history, physical examination, chest X-ray, tuberculin skin test and Interferon Gamma Release Assay (IGRA) test. We describe five clinical cases of patients who underwent biotechnological therapy at our Hospital after 2006 and developed TB.

Tuberculosis miliar inducida por instilación endovesical de bacilo de Calmette-Guérin / Miliary tuberculosis induced by intravesical instillation of bacillus Calmette-Guérin

La instilación endovesical de bacilo de Calmette-Guérin (BCG) es un tratamiento complementario eficaz para el cáncer de vejiga superficial, una vez realizada la resección transuretral. Se ha comprobado que este tratamiento retrasa la progresión tumoral, disminuye la probabilidad de que el paciente tenga que someterse a una cistectomía futura y mejora la supervivencia. En general se trata de un tratamiento eficaz y bien tolerado. Entre las complicaciones locales más frecuentes están el síndrome miccional irritativo, la hematuria y casos de infección genitourinaria local. Las complicaciones sistémicas son mucho menos frecuentes. Presentamos el caso de un varón de 71 años, en tratamiento con bacilo de Calmette-Guérin intravesical por cáncer de vejiga, que presenta de forma adversa una tuberculosis miliar secundaria al tratamiento. Se trata de una complicación excepcional por su frecuencia, potencialmente letal y que requiere la interrupción inmediata del tratamiento

The intravesical instillation of bacillus Calmette-Guérin (BCG) is an efficacious complementary treatment for superficial bladder cancer after transurethral resection. This treatment delays progression, decreases the probability that the patient will have to undergo cystectomy in the future, and improves survival; it is generally efficacious and well tolerated. Among the most common local complications are irritative symptoms, hematuria, local genitourinary infection. Systemic complications are much less common. We present the case of a 71-year-old man who developed miliary tuberculosis secondary to treatment with intravesical bacillus Calmette-Guérin for bladder cancer. This is exceptionally uncommon complication is potentially lethal and requires the immediate discontinuation of treatment

A Rare Case of Granulomatous Pneumonitis Due to Intravesical BCG for Bladder Cancer.

Granulomatous pneumonitis is a rare complication of bacillus Calmette-Guerin immunotherapy following intravesical administration of bacillus Calmette-Guerin. The authors present an unusual case of a 67-year-old man who developed mild and non-specific symptoms, following intravesical bacillus Calmette-Guerin instillations. Examinations revealed features of miliary tuberculosis and granuloma suggestive of mycobacterial infection. Anti-tuberculosis treatment resulted in a remarkable improvement in his symptoms and gradually upgrading of radiological appearance. The symptoms were less severe than some others described but this case provides evidence that, even in some cases, specific treatment may be necessary. We highlight the importance of recognizing miliary Mycobacterium bovis as a probable complication of bacillus Calmette-Guerin immunotherapy. The clinical disease course can be mild, despite extensive bilateral miliary nodules on primary presentation.

A pneumonite granulomatosa é uma complicação rara da imunoterapia com bacillus Calmette-Guerin após administração intravesical de bacillus Calmette-Guerin. Os autores apresentam um caso incomum de um homem de 67 anos de idade que desenvolveu sintomas ligeiros e inespecíficos, após instilações de bacillus Calmette-Guerin intravesical. Os xames revelaram características da tuberculose miliar e granuloma sugestivo de infeção por micobactérias. O tratamento antibacilar resultou numa melhoria notável na sua sintomatologia e na melhoria progressiva das alterações radiológicas. Os sintomas foram de menor gravidade comparativamente a outros casos relatados na literatura, mas este caso fornece evidências de que, mesmo em algumas situações, um tratamento específico pode ser necessário. Destacamos a importância de reconhecer o Mycobacterium bovis disseminado como uma provável complicação da imunoterapia a bacillus Calmette-Guerin. O curso clínico da doença pode ser ligeiro, apesar da extensa disseminação miliar bilateral na apresentação primária.

Miliary tuberculosis induced by intravesical instillation of bacillus Calmette-Guérin. / Tuberculosis miliar inducida por instilación endovesical de bacilo de Calmette-Guérin.

The intravesical instillation of bacillus Calmette-Guérin (BCG) is an efficacious complementary treatment for superficial bladder cancer after transurethral resection. This treatment delays progression, decreases the probability that the patient will have to undergo cystectomy in the future, and improves survival; it is generally efficacious and well tolerated. Among the most common local complications are irritative symptoms, hematuria, local genitourinary infection. Systemic complications are much less common. We present the case of a 71-year-old man who developed miliary tuberculosis secondary to treatment with intravesical bacillus Calmette-Guérin for bladder cancer. This is exceptionally uncommon complication is potentially lethal and requires the immediate discontinuation of treatment.

Predictors and outcomes of disseminated tuberculosis in an intermediate burden setting.

SETTING: University-affiliated hospital located in Porto, North Portugal, an area with a low to intermediate incidence of tuberculosis (TB). OBJECTIVE: To identify predictors and outcomes of disseminated TB (dTB). DESIGN: A cohort of patients diagnosed with TB between 2007 and 2013 was retrospectively analysed. Patients with dTB criteria were characterized and compared to single organ TB cases. Factors independently associated with dTB were determined by multivariate logistic regression analysis. RESULTS: A total of 744 patients were analysed, including 145 with dTB. Independent risk factors for dTB were pharmacological immunosuppression (OR 5.6, 95% CI 2.8-11.3), HIV infection (OR 5.1, 95% CI 3.1-8.3), chronic liver failure or cirrhosis (OR 2.3, 95% CI 1.4-4.1) and duration of symptoms (OR 2.3, 95% CI 1.4-3.8). Compared to single organ TB, the clinical presentation of dTB patients differed by the absence of haemoptysis (OR 3.2, 95% CI 1.3-8.4) and of dyspnoea (OR 1.9, 95% CI 1.2-3.1), presence of weight loss (OR 1.8, 95% CI 1.1-2.9), night sweats (OR 1.7, 95% CI 1.1-2.7) and bilateral lung involvement (OR 4.4, 95% CI 2.8-7.1). Mortality and time until culture conversion were higher for dTB patients, although not reaching statistical significance. CONCLUSION: Immunosuppressive conditions and chronic liver failure or cirrhosis were associated with increased risk of dTB. The haematogenous spread may be dependent on longer symptomatic disease and usually progresses with bilateral lung involvement.

Characteristics of miliary tuberculosis in pregnant women after in vitro fertilisation and embryo transfer.

OBJECTIVE: To analyse the clinical characteristics of miliary tuberculosis (TB) in pregnant women after in vitro fertilisation and embryo transfer (IVF-ET). METHODS: Six pregnant women with miliary TB after IVF-ET between October 2010 and July 2015 were retrospectively analysed. RESULTS: The patients were aged between 29 and 39 years. Fever, cough and dyspnoea were the main symptoms, and started during the first and second trimesters of pregnancy. Erythrocyte sedimentation rate and C-reactive protein were increased. White blood cell count was normal or slightly increased. Tuberculin purified protein derivative and acid-fast smear of sputum tests were negative. T-SPOT®.TB was performed in two cases and the results were positive. Chest computed tomography showed typical miliary nodules. One patient had tuberculous meningitis. Although all patients were cured, the foetuses died. CONCLUSIONS: The principal symptoms of miliary TB in pregnant women after IVF-ET were fever and dyspnoea. Physicians should consider the occurrence of miliary TB, particularly in the case of fever of long duration, respiratory symptoms and no response to antibiotic treatment.

Miliary pulmonary infection after BCG intravesical instillation: a rare, misdiagnosed and mistreated complication.

Intravesical Bacillus Calmette-Guérin (BCG) immunotherapy decreases the progression risk of non-muscle-invasive bladder cancer, but potentially yields a broad spectrum of side effects. We report the case of a 73-year-old man affected by miliary pulmonary BCG infection, whose microbiological diagnosis was probably hindered by empiric fluoroquinolones, focusing on imaging and clinical work-up.