Abstract

Intravesical therapy of Bacillus Calmette-Guerin (BCG) is an adjuvant treatment for bladder cancer recommended after transurethral resection of all visible bladder tumor (TURBT). We report a case of an 80-year-old male with a history of T1 high grade bladder cancer with subsequent TURBT and six intravesical treatments of BCG presenting six months later with disseminated BCG (BCG-osis). Our patient presented with a two-month history of numerous, discrete, red-brown papules, predominantly involving his left abdomen and left lower extremity with associated fatigue and weakness. Two punch biopsies of the left thigh revealed granulomatous dermatitis with deep necrotizing granulomas. Infectious staining of AFB and GMS were negative. Tissue cultures for both fungal and AFB were negative. A bone marrow biopsy revealed clonal CD8 positive T-cell population consistent with T-cell large granular lymphoproliferative disorder and multifocal non-necrotizing granulomas. Infectious stains of the granulomas were negative for AFB and GMS stains. PCR from the paraffin embedded tissue containing the necrotizing granuloma was negative for mycobacterium, but the report noted that this does not exclude the diagnosis. Based on the presence of granulomas within his skin and bone marrow and clinical history, a diagnosis of BCG-osis was proposed and the patient was referred to infectious disease and began multidrug therapy of rifampin, ethambutol, and isoniazid. Disseminated BCG after intravesical therapy has been reported in the literature associated with genitourinary complications and systemic complications. Cutaneous manifestations have been reported, but limited to the genitocrural region and organisms are not readily found on special stains. We present this case of both cutaneous and extracutaneous manifestations of disseminated BCG to highlight the importance of considering BCG-osis in patients with granulomatous dermatitis following traumatic intravesical BCG.

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