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BCGite, um desafio diagnóstico : a propósito de um caso clínico
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A instilação intravesical do bacilo Calmette-Guérin (BCG) está indicada no tratamento e prevenção da recidiva do carcinoma superficial de alto grau da bexiga e do carcinoma in situ. Apesar de considerada uma terapêutica segura estão descritas complicações locais e sistémicas. Estas complicações são raras, apresentando uma incidência cumulativa inferior a 5%, mas de particular relevância pela potencial severidade clínica e pela dificuldade do diagnóstico que, muitas vezes, representam para o clínico. Apresenta-se o caso de um homem de 80 anos com carcinoma do urotélio vesical que foi tratado com instilações intravesicais do BCG. Cerca de um ano após o início da imunoterapia, iniciou quadro de astenia, febre baixa, sudorese noturna e perda ponderal e, alguns meses depois, teve um episódio inaugural de crise convulsiva. Apresentava pancitopenia (Hb: 7,9 g/dL, leucócitos: 3 120/μL, plaquetas: 129 000/μL) e o exame citoquímico do líquido cefalorraquidiano mostrava 20 células/mm3, com predomínio de linfócitos, glicose diminuída e proteínas e adenosina deaminase elevadas. Os exames de imagem documentaram hepatoesplenomegalia e aneurismas micóticos na aorta abdominal. Os achados do exame histopatológico da biópsia osteomedular foram sugestivos de mielite granulomatosa. No exame microbiológico do sangue medular e do lavado-broncoalveolar foi identificado Mycobacterium bovis. Admitiu-se o diagnóstico de infeção disseminada por Mycobacterium bovis, com envolvimento meníngeo, pulmonar, vascular e da medula óssea, como complicação da instilação intravesical do BCG. Instituiu-se terapêutica com isoniazida, rifampicina e etambutol. A apresentação deste caso pretende alertar para complicações raras de uma terapêutica frequente. O envolvimento meníngeo e vascular é incomum e na literatura estão descritos apenas 13 casos de infecção da medula óssea pelo Mycobacterium bovis atenuado. O reconhecimento das complicações da imunoterapia com BCG é fundamental para o início precoce da terapêutica.
Intravesical instillation of bacilleCalmette-Guérin (BCG) is indicated for the treatment and prevention of recurrance of high grade superficial bladder cancer and carcinoma in situ of the bladder. Although considered a safe therapy, local and systemic complications have been described. These complications are uncommon, with a cumulative incidence lower than 5%, they assume particular relevance due to its potential severity for the patient and also because it poses a diagnostic challenge for the clinician. We report the case of an 80-year-old man with superficial bladder cancer who had been treated with intravesical BCG instillations. About a year after the start of immunotherapy, he presented with asthenia, low fever, night sweats and weight loss, and a few months later had a first-time seizure episode. He presented pancytopenia (Hb: 7,9 g/dL, leukocytes: 3 120/μL, platelets: 129,000/μL) and cytochemical examination of cerebrospinal fluid followed showed 20 cells / mm3, with predominance of lymphocytes, decreased glucose and elevated proteins and adenosine deaminase activity. The imaging studies documented hepatosplenomegaly and mycotic aneurysms in the abdominal aorta. The findings of the histopathological examination of the bone marrow biopsy were suggestive of granulomatous myelitis. In the microbiological examination of the blood from the bone marrow and the bronchoalveolar lavage was identified Mycobacterium bovis. We admitted the diagnosis of disseminated Mycobacterium bovis infection with meningeal, pulmonary, vascular and bone marrow involvement, as a complication of intravesical BCG instillation. Therapy with isoniazid, rifampicin and ethambutol was started. The presentation of this case is intended to alert to rare complications of a frequent therapy. Meningeal and vascular involvement is uncommon and in the literature only 13 cases of bone marrow infection by attenuated Mycobacterium bovis have been described. Recognition of the complications of BCG immunotherapy is critical for the early initiation of therapy.
Intravesical instillation of bacilleCalmette-Guérin (BCG) is indicated for the treatment and prevention of recurrance of high grade superficial bladder cancer and carcinoma in situ of the bladder. Although considered a safe therapy, local and systemic complications have been described. These complications are uncommon, with a cumulative incidence lower than 5%, they assume particular relevance due to its potential severity for the patient and also because it poses a diagnostic challenge for the clinician. We report the case of an 80-year-old man with superficial bladder cancer who had been treated with intravesical BCG instillations. About a year after the start of immunotherapy, he presented with asthenia, low fever, night sweats and weight loss, and a few months later had a first-time seizure episode. He presented pancytopenia (Hb: 7,9 g/dL, leukocytes: 3 120/μL, platelets: 129,000/μL) and cytochemical examination of cerebrospinal fluid followed showed 20 cells / mm3, with predominance of lymphocytes, decreased glucose and elevated proteins and adenosine deaminase activity. The imaging studies documented hepatosplenomegaly and mycotic aneurysms in the abdominal aorta. The findings of the histopathological examination of the bone marrow biopsy were suggestive of granulomatous myelitis. In the microbiological examination of the blood from the bone marrow and the bronchoalveolar lavage was identified Mycobacterium bovis. We admitted the diagnosis of disseminated Mycobacterium bovis infection with meningeal, pulmonary, vascular and bone marrow involvement, as a complication of intravesical BCG instillation. Therapy with isoniazid, rifampicin and ethambutol was started. The presentation of this case is intended to alert to rare complications of a frequent therapy. Meningeal and vascular involvement is uncommon and in the literature only 13 cases of bone marrow infection by attenuated Mycobacterium bovis have been described. Recognition of the complications of BCG immunotherapy is critical for the early initiation of therapy.
Descrição
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2018
Palavras-chave
Instilações intra-vesicais de BCG Carcinoma da bexiga BCGite Medula óssea