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Linfadenitis granulomatosa mediastínica tras tratamiento con bacilo Calmette-Guérin intravesical que simula metástasis distante de carcinoma vesical primario
Mediastinal granulomatous lymphadenitis after intravesical bacillus Calmette-Guerin treatment mimicking distant metastasis of primary bladder carcinoma
Deniz Dogana, Murat Zora,
, Tuncer Ozkisaa, Omer Aytenb, Nuri Yigitc, Ismail Yavasd
Corresponding author
a Department of Pulmonary Diseases, Gulhane Military Hospital, Ankara, Turkey
b Department of Pulmonary Diseases, Gulhane Military Hospital, Istanbul, Turkey
c Department of Pathology, Gulhane Military Hospital, Ankara, Turkey
d Department of Pulmonary Diseases, Ankara University Medical Faculty, Ankara, Turkey
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] ] ] 2 => array:3 [ "nombre" => "Tuncer" "apellidos" => "Ozkisa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Omer" "apellidos" => "Ayten" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "Nuri" "apellidos" => "Yigit" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 5 => array:3 [ "nombre" => "Ismail" "apellidos" => "Yavas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Department of Pulmonary Diseases, Gulhane Military Hospital, Ankara, Turkey" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Pulmonary Diseases, Gulhane Military Hospital, Istanbul, Turkey" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Pathology, Gulhane Military Hospital, Ankara, Turkey" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Department of Pulmonary Diseases, Ankara University Medical Faculty, Ankara, Turkey" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Autor para correspondencia." ] ] ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Mediastinal granulomatous lymphadenitis after intravesical bacillus Calmette-Guerin treatment mimicking distant metastasis of primary bladder carcinoma" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 551 "Ancho" => 1452 "Tamanyo" => 172213 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A) Vista ecográfica endobronquial de la lesión sospechosa. B) Formación granulomatosa (tinción hematoxilina-eosina ×200).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">En nuestro servicio ingresó un varón de 38 años con dolor y sensibilidad torácicos de un mes de evolución y que se habían exacerbado gradualmente en los últimos días. La exploración sistémica y las constantes vitales fueron normales. En sus antecedentes constaba una hematuria asintomática microscópica 3 años antes que llevó a diagnóstico de carcinoma vesical. Había recibido 16 ciclos de tratamiento con el bacilo Calmette-Guérin (BCG) que habían terminado hacía aproximadamente 16 meses. Para descartar la posibilidad de metástasis distante en la pared torácica se realizó una gammagrafía ósea de cuerpo entero. Al detectar el aumento de actividad a la altura de la 5.ª costilla, decidimos realizar una tomografía por emisión de positrones/tomografía computarizada (PET/TC) de cuerpo entero con <span class="elsevierStyleSup">18</span>F-fluoro-2-deoxi-D-glucosa (<span class="elsevierStyleSup">18</span>F-FDG PET/TC). La <span class="elsevierStyleSup">18</span>F-FDG PET/TC reveló un incremento de actividad (SUV<span class="elsevierStyleInf">max</span>: 5,6) en la estación ganglionar linfática 11L, en la región hiliar izquierda. Aunque el prediagnóstico había sido metástasis del carcinoma vesical primario, el análisis histopatológico de las muestras obtenidas mediante punción-aspiración transbronquial guiada por ecografía endobronquial (<a class="elsevierStyleCrossRef" href="#fig0005">fig. 1</a>A) reveló la presencia de linfadenitis granulomatosa (<a class="elsevierStyleCrossRef" href="#fig0005">fig. 1</a>B). Por lo tanto, el paciente recibió tratamiento farmacológico empírico cuádruple frente a tuberculosis compuesto por isoniazida (300<span class="elsevierStyleHsp" style=""></span>mg/día), rifampicina (600<span class="elsevierStyleHsp" style=""></span>mg/día), etambutol (800<span class="elsevierStyleHsp" style=""></span>mg/día) y pirazinamida (1<span class="elsevierStyleHsp" style=""></span>g/día) durante 6 meses. En la PET de revisión a los 6 meses se observó que la captación FDG se había reducido (SUV<span class="elsevierStyleInf">max</span>: 1,1) en comparación con los niveles anteriores. El paciente no refirió molestias en la revisión al año.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">El BCG es una opción importante de tratamiento adyuvante para reducir el riesgo de recurrencia y el avance del carcinoma vesical<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a>. El tratamiento con BCG intravesical presenta algunas complicaciones sistémicas y localizadas, aunque son poco frecuentes. La mayoría de los efectos adversos localizados suelen ser autolimitados e incluyen hematuria, disuria, cistitis, prostatitis y orquitis. Sin embargo, los efectos adversos sistémicos son menos comunes y pueden ir desde una simple febrícula hasta una insuficiencia multiorgánica potencialmente mortal<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a>.</p><p id="par0015" class="elsevierStylePara elsevierViewall">En la bibliografía en inglés, existen varios estudios sobre casos de linfadenitis granulomatosa pulmonar o extrapulmonar secundarios a instilación de BCG. Existe un importante debate acerca de si las complicaciones infecciosas secundarias al BCG se deben a una reacción por hipersensibilidad o a infección activa. Algunos estudios han hallado bacterias viables en distintos tejidos, como pulmonar, pancreático o hepático, lo que indica una infección activa<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3,4</span></a>. Por su parte, la hipótesis de la hipersensibilidad está respaldada por los trabajos en los que no se pudieron aislar microorganismos<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a>. Ese ha sido nuestro caso, pues no pudimos evidenciar la presencia de bacilos acidorresistentes en 3 muestras de esputo ni en una de lavado broncoalveolar e incluso los resultados de los cultivos fueron negativos.</p><p id="par0020" class="elsevierStylePara elsevierViewall">En resumen, el valor de este caso reside en su ilustración de una complicación característica de la instilación de BCG intravesical. Con este artículo, esperamos resaltar la importancia de tener presentes las distintas complicaciones del tratamiento con BCG intravesical, aunque exista sospecha clínica de infección por BCG.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicto de intereses</span><p id="par0025" class="elsevierStylePara elsevierViewall">Sin conflicto de intereses ni financiación.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicto de intereses" ] 1 => array:1 [ "titulo" => "Bibliografía" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 551 "Ancho" => 1452 "Tamanyo" => 172213 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A) Vista ecográfica endobronquial de la lesión sospechosa. B) Formación granulomatosa (tinción hematoxilina-eosina ×200).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliografía" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guideline for the management of nonmuscle invasive bladder cancer (stages Ta, T1, and Tis): 2007 update" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.C. Hall" 1 => "S.S. Chang" 2 => "G. Dalbagni" 3 => "R.S. Pruthi" 4 => "J.D. Seigne" 5 => "E.C. Skinner" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.juro.2007.09.003" "Revista" => array:6 [ "tituloSerie" => "J Urol" "fecha" => "2007" "volumen" => "178" "paginaInicial" => "2314" "paginaFinal" => "2330" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17993339" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mycobacterial infection after intravesical bacillus Calmette-Guérin treatment for bladder cancer: A case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "C.H. Park" 1 => "M.A. Jang" 2 => "Y.H. Ahn" 3 => "Y.Y. Hwang" 4 => "C.S. Ki" 5 => "N.Y. Lee" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3343/kjlm.2011.31.3.197" "Revista" => array:6 [ "tituloSerie" => "Korean J Lab Med" "fecha" => "2011" "volumen" => "31" "paginaInicial" => "197" "paginaFinal" => "200" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21779195" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Miliary <span class="elsevierStyleItalic">Mycobacterium bovis</span> induced by intravesical bacille Calmette-Guérin immunotherapy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "C. McParland" 1 => "D.J. Cotton" 2 => "K.S. Gowda" 3 => "V.H. Hoeppner" 4 => "W.T. Martin" 5 => "P.F. Weckworth" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/ajrccm/146.5_Pt_1.1330" "Revista" => array:6 [ "tituloSerie" => "Am Rev Respir Dis" "fecha" => "1992" "volumen" => "146" "paginaInicial" => "1330" "paginaFinal" => "1333" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1443892" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Peritoneal tuberculosis and granulomatous hepatitis secondary to treatment of bladder cancer with bacillus Calmette-Guérin" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Soylu" 1 => "A.T. Ince" 2 => "H. Polat" 3 => "N. Yasar" 4 => "A. Ciltas" 5 => "S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 3 | 10 |
| 2024 October | 92 | 18 | 110 |
| 2024 September | 101 | 13 | 114 |
| 2024 August | 99 | 30 | 129 |
| 2024 July | 91 | 22 | 113 |
| 2024 June | 89 | 22 | 111 |
| 2024 May | 72 | 26 | 98 |
| 2024 April | 59 | 24 | 83 |
| 2024 March | 61 | 24 | 85 |
| 2024 February | 47 | 43 | 90 |
| 2023 March | 16 | 4 | 20 |
| 2023 February | 74 | 16 | 90 |
| 2023 January | 51 | 36 | 87 |
| 2022 December | 54 | 38 | 92 |
| 2022 November | 90 | 33 | 123 |
| 2022 October | 50 | 41 | 91 |
| 2022 September | 54 | 40 | 94 |
| 2022 August | 56 | 34 | 90 |
| 2022 July | 48 | 36 | 84 |
| 2022 June | 56 | 29 | 85 |
| 2022 May | 52 | 30 | 82 |
| 2022 April | 59 | 26 | 85 |
| 2022 March | 60 | 37 | 97 |
| 2022 February | 91 | 25 | 116 |
| 2022 January | 77 | 25 | 102 |
| 2021 December | 65 | 31 | 96 |
| 2021 November | 66 | 45 | 111 |
| 2021 October | 64 | 50 | 114 |
| 2021 September | 52 | 40 | 92 |
| 2021 August | 76 | 35 | 111 |
| 2021 July | 45 | 29 | 74 |
| 2021 June | 60 | 41 | 101 |
| 2021 May | 53 | 35 | 88 |
| 2021 April | 111 | 40 | 151 |
| 2021 March | 87 | 29 | 116 |
| 2021 February | 79 | 30 | 109 |
| 2021 January | 57 | 29 | 86 |
| 2020 December | 54 | 27 | 81 |
| 2020 November | 68 | 24 | 92 |
| 2020 October | 54 | 20 | 74 |
| 2020 September | 41 | 13 | 54 |
| 2020 August | 50 | 19 | 69 |
| 2020 July | 58 | 29 | 87 |
| 2020 June | 47 | 16 | 63 |
| 2020 May | 47 | 13 | 60 |
| 2020 April | 45 | 13 | 58 |
| 2020 March | 42 | 24 | 66 |
| 2020 February | 53 | 23 | 76 |
| 2020 January | 67 | 19 | 86 |
| 2019 December | 77 | 19 | 96 |
| 2019 November | 45 | 28 | 73 |
| 2019 October | 47 | 8 | 55 |
| 2019 September | 83 | 8 | 91 |
| 2019 August | 58 | 15 | 73 |
| 2019 July | 71 | 24 | 95 |
| 2019 June | 60 | 12 | 72 |
| 2019 May | 111 | 10 | 121 |
| 2019 April | 96 | 16 | 112 |
| 2019 March | 62 | 17 | 79 |
| 2019 February | 55 | 13 | 68 |
| 2019 January | 68 | 17 | 85 |
| 2018 December | 66 | 20 | 86 |
| 2018 November | 86 | 12 | 98 |
| 2018 October | 138 | 15 | 153 |
| 2018 September | 66 | 8 | 74 |
| 2018 July | 2 | 0 | 2 |
| 2018 May | 20 | 0 | 20 |
| 2018 April | 32 | 7 | 39 |
| 2018 March | 33 | 4 | 37 |
| 2018 February | 45 | 8 | 53 |
| 2018 January | 26 | 8 | 34 |
| 2017 December | 51 | 13 | 64 |
| 2017 November | 38 | 8 | 46 |
| 2017 October | 35 | 13 | 48 |
| 2017 September | 30 | 6 | 36 |
| 2017 August | 43 | 17 | 60 |
| 2017 July | 16 | 4 | 20 |
| 2017 June | 46 | 12 | 58 |
| 2017 May | 54 | 13 | 67 |
| 2017 April | 27 | 6 | 33 |
| 2017 March | 26 | 12 | 38 |
| 2017 February | 26 | 7 | 33 |
| 2017 January | 13 | 3 | 16 |
| 2016 December | 39 | 7 | 46 |
| 2016 November | 60 | 9 | 69 |
| 2016 October | 56 | 14 | 70 |
| 2016 September | 64 | 15 | 79 |
| 2016 August | 65 | 12 | 77 |
| 2016 July | 57 | 10 | 67 |
| 2016 June | 68 | 18 | 86 |
| 2016 May | 72 | 15 | 87 |
| 2016 April | 63 | 3 | 66 |
| 2016 March | 44 | 18 | 62 |
| 2016 February | 41 | 11 | 52 |
| 2016 January | 73 | 19 | 92 |
| 2015 December | 7 | 1 | 8 |
| 2015 November | 20 | 2 | 22 |
| 2015 October | 42 | 1 | 43 |
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