Letter to the Editor
Mediastinal Granulomatous Lymphadenitis After Intravesical Bacillus Calmette–Guérin Treatment Mimicking Distant Metastasis of Primary Bladder Carcinoma
Linfadenitis granulomatosa mediastínica tras tratamiento con bacilo Calmette–Guérin intravesical que simula metástasis distante de carcinoma vesical primario
Deniz Dogana, Murat Zora,
, Tuncer Ozkisaa, Omer Aytenb, Nuri Yigitc, Ismail Savasd
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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"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" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Linfadenitis granulomatosa mediastínica tras tratamiento con bacilo Calmette–Guérin intravesical que simula metástasis distante de carcinoma vesical primario" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 551 "Ancho" => 1452 "Tamanyo" => 175326 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Endobronchial ultrasound view of the suspicious lesion. (B) Granulomatous formation (hematoxylin–eosin staining ×200).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 38-year-old man was admitted to our department with a 1-month history of chest pain and sensitivity that had gradually worsened in the previous few days. Systemic examination and vital signs were normal. His medical record indicated a history of asymptomatic microscopic hematuria diagnosed as bladder carcinoma 3 years previously. He had completed 16 cycles of bacillus Calmette–Guérin (BCG) approximately 16 months earlier. A whole body bone scan was performed to rule out distance metastasis in the chest wall, but after detecting increased activity at the level of the 5th rib, we decided to perform whole body positron emission tomography/computed tomography (PET/CT) with <span class="elsevierStyleSup">18</span>F-fluoro-2-deoxy-<span class="elsevierStyleSmallCaps">d</span>-glucose (<span class="elsevierStyleSup">18</span>F-FDG PET/CT). This revealed increased activity (SUV<span class="elsevierStyleInf">max</span>: 5.6) in lymph node station 11L, in the left hilar region. Although the preliminary diagnosis had been primary bladder carcinoma metastasis, histological analysis of the samples obtained by endobronchial ultrasound-guided fine needle aspiration (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A) revealed granulomatous lymphadenitis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). The patient therefore received empirical quadruple pharmacological tuberculosis treatment, consisting of isoniazide (300<span class="elsevierStyleHsp" style=""></span>mg/day), rifampicin (600<span class="elsevierStyleHsp" style=""></span>mg/day), ethambutol (800<span class="elsevierStyleHsp" style=""></span>mg/day) and pyrazinamide (1<span class="elsevierStyleHsp" style=""></span>g/day) for 6 months. Follow-up PET performed 6 months later showed a decrease in FDG uptake (SUV<span class="elsevierStyleInf">max</span>: 1.1) compared to previous levels. The patient did not report any discomfort at his 1-year check-up.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">BCG is an important adjuvant treatment option for reducing the risk of recurrence and progression of bladder carcinoma.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Although rare, intravesical BCG treatment can present systemic and localized complications. Most localized adverse effects are generally self-limiting, and include hematuria, dysuria, cystitis, prostatitis, and orchitis. Systemic adverse effects, however, are less common, and can range from simple febricula to potentially fatal multi-organ failure.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Several cases of pulmonary or extra-pulmonary granulomatous lymphadenitis secondary to BCG instillation have been described in the English-language literature. However, there is considerable debate on whether the infectious complications secondary to BCG are due to a hypersensitivity reaction or to active infection. Some studies have found viable bacteria in different tissues, such as the lung, pancreas and liver, suggesting active infection.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3,4</span></a> The hypersensitivity hypothesis, meanwhile, is supported by studies in which microorganisms could not be isolated.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> This was the case in our patient, as we were unable to demonstrate the presence of acid-fast bacilli in 3 sputum samples and 1 bronchoalveolar lavage sample; culture results were also negative.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In summary, this case is of interest insofar as it illustrates a characteristic complication of intravesical BCG instillation. We hope this report will highlight the importance of bearing in mind the different complications of intravesical BCG treatment, even when there is clinical suspicion of BCG infection.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests or funding to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interests" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Dogan D, Zor M, Ozkisa T, Ayten O, Yigit N, Yavas I. Linfadenitis granulomatosa mediastínica tras tratamiento con bacilo Calmette–Guérin intravesical que simula metástasis distante de carcinoma vesical primario. Arch Bronconeumol. 2015;51:526–527.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 551 "Ancho" => 1452 "Tamanyo" => 175326 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Endobronchial ultrasound view of the suspicious lesion. (B) Granulomatous formation (hematoxylin–eosin staining ×200).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "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. 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Ozkara" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/1476-0711-8-12" "Revista" => array:5 [ "tituloSerie" => "Ann Clin Microbiol Antimicrob" "fecha" => "2009" "volumen" => "8" "paginaInicial" => "12" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19368735" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Disseminated <span class="elsevierStyleItalic">Mycobacterium bovis</span> after intravesicular bacillus Calmette–Guérin treatments for bladder cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. Elkabani" 1 => "J.N. Greene" 2 => "A.L. Vincent" 3 => "S. VanHook" 4 => "R.L. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 4 | 9 |
| 2024 October | 62 | 20 | 82 |
| 2024 September | 65 | 16 | 81 |
| 2024 August | 86 | 42 | 128 |
| 2024 July | 48 | 15 | 63 |
| 2024 June | 72 | 34 | 106 |
| 2024 May | 97 | 26 | 123 |
| 2024 April | 45 | 27 | 72 |
| 2024 March | 42 | 17 | 59 |
| 2024 February | 37 | 28 | 65 |
| 2023 March | 6 | 4 | 10 |
| 2023 February | 60 | 20 | 80 |
| 2023 January | 44 | 21 | 65 |
| 2022 December | 58 | 28 | 86 |
| 2022 November | 79 | 32 | 111 |
| 2022 October | 53 | 32 | 85 |
| 2022 September | 51 | 34 | 85 |
| 2022 August | 61 | 36 | 97 |
| 2022 July | 37 | 38 | 75 |
| 2022 June | 48 | 41 | 89 |
| 2022 May | 70 | 32 | 102 |
| 2022 April | 87 | 29 | 116 |
| 2022 March | 89 | 38 | 127 |
| 2022 February | 98 | 32 | 130 |
| 2022 January | 57 | 28 | 85 |
| 2021 December | 61 | 44 | 105 |
| 2021 November | 51 | 45 | 96 |
| 2021 October | 64 | 43 | 107 |
| 2021 September | 42 | 42 | 84 |
| 2021 August | 40 | 27 | 67 |
| 2021 July | 44 | 27 | 71 |
| 2021 June | 65 | 40 | 105 |
| 2021 May | 82 | 24 | 106 |
| 2021 April | 114 | 57 | 171 |
| 2021 March | 83 | 31 | 114 |
| 2021 February | 50 | 22 | 72 |
| 2021 January | 42 | 22 | 64 |
| 2020 December | 50 | 17 | 67 |
| 2020 November | 28 | 28 | 56 |
| 2020 October | 23 | 13 | 36 |
| 2020 September | 21 | 6 | 27 |
| 2020 August | 35 | 23 | 58 |
| 2020 July | 36 | 23 | 59 |
| 2020 June | 48 | 7 | 55 |
| 2020 May | 61 | 19 | 80 |
| 2020 April | 37 | 27 | 64 |
| 2020 March | 33 | 20 | 53 |
| 2020 February | 32 | 23 | 55 |
| 2020 January | 44 | 25 | 69 |
| 2019 December | 43 | 22 | 65 |
| 2019 November | 33 | 23 | 56 |
| 2019 October | 39 | 17 | 56 |
| 2019 September | 43 | 5 | 48 |
| 2019 August | 25 | 15 | 40 |
| 2019 July | 33 | 15 | 48 |
| 2019 June | 36 | 12 | 48 |
| 2019 May | 39 | 11 | 50 |
| 2019 April | 50 | 20 | 70 |
| 2019 March | 40 | 26 | 66 |
| 2019 February | 36 | 23 | 59 |
| 2019 January | 33 | 30 | 63 |
| 2018 December | 39 | 20 | 59 |
| 2018 November | 45 | 25 | 70 |
| 2018 October | 90 | 23 | 113 |
| 2018 September | 57 | 14 | 71 |
| 2018 May | 28 | 0 | 28 |
| 2018 April | 39 | 8 | 47 |
| 2018 March | 45 | 5 | 50 |
| 2018 February | 36 | 8 | 44 |
| 2018 January | 45 | 6 | 51 |
| 2017 December | 43 | 6 | 49 |
| 2017 November | 27 | 10 | 37 |
| 2017 October | 24 | 10 | 34 |
| 2017 September | 17 | 20 | 37 |
| 2017 August | 20 | 15 | 35 |
| 2017 July | 20 | 11 | 31 |
| 2017 June | 39 | 17 | 56 |
| 2017 May | 37 | 8 | 45 |
| 2017 April | 34 | 15 | 49 |
| 2017 March | 27 | 12 | 39 |
| 2017 February | 16 | 7 | 23 |
| 2017 January | 21 | 6 | 27 |
| 2016 December | 26 | 12 | 38 |
| 2016 November | 35 | 8 | 43 |
| 2016 October | 42 | 15 | 57 |
| 2016 September | 28 | 19 | 47 |
| 2016 August | 56 | 13 | 69 |
| 2016 July | 41 | 19 | 60 |
| 2016 May | 0 | 8 | 8 |
| 2016 April | 0 | 1 | 1 |
| 2016 March | 2 | 0 | 2 |
| 2016 February | 1 | 3 | 4 |
| 2016 January | 0 | 11 | 11 |
| 2015 October | 1 | 1 | 2 |
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