Miliare Pneumonie nach intravesikaler BCG-Therapie einesoberflächlichen Urothelkarzinoms der Harnblase

HISTORY AND ADMISSION FINDINGS: A multilocular superficial epithelial carcinoma (T1G3) and carcinoma in situ (Cis G3) of the bladder were resected transurethrally followed by intravesical instillation of BCG. The initial cycle of BCG administration had been free of complication, but then high fever, fatigue, cough and dyspnoea had developed with subsequent BCG maintenance treatment. Physical examination on admission revealed fever, clearly reduced general condition, and increased breath sounds with fine rales in the upper and middle lobes. INVESTIGATIONS: A clearly raised erythrocyte sedimentation rate (86 mm/h) and a CRP level at the upper limit of normal (13.6 mg/dl) indicated marked inflammatory reaction. The chest radiogram showed diffuse miliary opacities. Mycobacteria were not demonstrated in either gastric juice or bronchial secretion. TREATMENT AND COURSE: As BCG-induced miliary pneumonia was diagnosed, triple tuberculostatic treatment was commenced (ethambutol, 1200 mg/d; rifampicin, 600 mg/d; isoniazid, 300 mg/d). Nonetheless his condition deteriorated further. When prednisolone, 40 mg/d was added the symptoms improved rapidly. The tuberculostatic drugs were continued for 6 months. All symptoms had disappeared after 4 months. CONCLUSION: Miliary pneumonia is a rare complication of intravesical BCG installation of a superficial bladder cancer. As living bacteria cannot be excluded as the cause, triple tuberculostatic treatment must be started at once. If this fails to bring about improvement, additional steroid medication is recommended.