1. Case details
This case report describes a man aged 60 yr with multiple pT1 grade 3 bladder tumours. With this pathology, there is an indication for bacillus Calmette-Guérin (BCG) instillations to reduce recurrence. During the instillations, this patient presented with malaise and back pain, which appeared to be a mycotic aneurysm of the abdominal aorta. After 6 mo, BCG was continued, and this was followed again by malaise, night sweating, and back pain. Positron emission tomography and computed tomography (CT) showed a psoas abscess.
Mycotic aneurysm is a serious complication of intravesical BCG instillation. Fortunately, this complication is not common. In the case report, after reconstruction of the aneurysm with an endostent, there was a second complication: a psoas abscess. Should BCG be continued in this case? Is prophylactic treatment necessary? And what is the best way to repair the aneurysm at that moment? We tried to answer these important questions.
As discussed in the case report, 20 cases of mycotic abdominal aortic aneurysm as a complication of BCG have been reported in the literature. In addition, a few cases of mycotic aneurysm of the thoracic aorta  and femoral , carotid , and popliteal  arteries have been described. Consequently, when vascular screening before starting BCG is considered, all of the large arteries should be considered. Although the exact incidence of mycotic aneurysm after BCG is not known, and despite the fact that a mycotic aneurysm can be life-threatening, it seems that the incidence is so low that screening is not likely to be a cost-effective procedure.
In the work-up for haematuria, at least an ultrasound will be performed in which abdominal aneurysms can be detected. Guidelines even advise CT urography or intravenous urography at the time of diagnosis of non–muscle-invasive bladder cancer (NMIBC) in selected cases, such as those with multiple- or high-risk tumours. Preexisting abdominal aneurysm will be diagnosed by CT.
Intravesical BCG therapy has an important role in the treatment of NMIBC to reduce the risk of progression or recurrence. There are many BCG schedules, most of which start with a weekly induction schedule for 6 wk. The case report mentioned a re-resection after three instillations and then a weekly BCG schedule for 6 wk. After the second of three instillations, the contained rupture of the abdominal aorta was diagnosed and an endostent was placed. About 5 mo later, weekly BCG maintenance continued for 3 wk. After this session, an infectious complication occurred again and BCG was stopped. After the introduction schedule of six instillations, a maintenance schedule is recommended for the prevention of recurrence or progression . There is no consensus about the exact maintenance schedule, so caution is wise when a serious complication has already occurred, for example, by giving only two or three BCG instillations after the initial six instillations or perhaps by dose reduction.
Reducing the dose does not seem useful according to the results of a European Organisation for Research and Treatment of Cancer (EORTC) study group; there was no difference in toxicity between one-third and full-dose BCG, but the one-third dose of BCG was associated with a higher recurrence rate, especially when given for only 1 yr  and . In contrast, other studies showed that a half-dose BCG instillation resulted in fewer side effects, without differences in recurrence or progression . A meta-analysis even reported a 48% lower risk of severe side effects for low-dose BCG . Although none of these reports mentioned a systemic BCG infection, as in this case report, perhaps a dose reduction in this case would have been appropriate, considering the many BCG side effects from the start.
Tuberculostatic agents, such as isoniazid, are used to diminish or treat the local irritative symptoms and systemic side effects caused by intravesical BCG. Another EORTC study showed that prophylactic administration of isoniazid during BCG instillations provides no decrease in any known side effect of BCG . Alternatively, Colombel et al. showed a decrease in incidence of moderate and severe adverse events during BCG with ofloxacin ; however, there were no complications such as infectious aneurysms, so whether early preventive therapy would have made sense in this case remains questionable.
Treatment of an infectious aneurysm with an endostent is questionable. The major concern is persistent infection or reinfection of the graft. Muller et al. described repair of 33 mycotic aneurysms of thoracic and abdominal aortas and iliac arteries. In situ repair with patch plasty or tube graft does not seem to be related to higher morbidity or mortality compared with revascularisation with extra-anatomic procedures . More case reports are available in which endovascular grafting was a successful treatment of infected abdominal aortic aneurysm . According to vascular surgeons, the indications for endograft repair of infected aneurysms have remained inconclusive (pers. comm.). Nevertheless, based on the little available evidence, an endostent is an option. In these cases, if cultures are positive for Mycobacterium bovis, long-term treatment with antituberculous therapy is advisable.
Continuing BCG after an endostent depends on multiple factors: the pathology results of the initial bladder tumour, the number of instillations already given, the results of blood culture and CT scan after the endostent procedure, and the condition of the patient. We feel, however, that reintroduction of BCG would seem one step too far after a proven systemic BCG infection, as in this case.
3. Treatment strategy
After an infectious complication caused by BCG, consider a dose reduction. It is unlikely that isoniazid prophylaxis prevents infectious complications such as those in this case. Treatment of a mycotic aneurysm with an endostent seems safe, based on the little available evidence; however, continuation of BCG after mycotic aneurysm treatment is not advised.
Conflicts of interest
The authors have nothing to disclose.
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Department of Urology, Radboud University Medical Centre, Nijmegen, The Netherlands
Corresponding author. Department of Urology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, Nijmegen, 6525GA, The Netherlands. Tel. +31 00614657323.
© 2016 European Association of Urology, Published by Elsevier B.V.