Scientific Letter
Pleural Effusion After Intravesical Administration of Bacillus Calmette-Guérin
Derrame pleural tras tratamiento intravesical con bacilo de Calmette-Guérin
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Javier García-Pérez, Diego Domingo" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Ana" "apellidos" => "Roca Noval" "email" => array:1 [ 0 => "anaroca14@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Carolina" "apellidos" => "Cisneros" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "F. Javier" "apellidos" => "García-Pérez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Diego" "apellidos" => "Domingo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Neumología, Hospital Universitario La Princesa, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Microbiología, Hospital Universitario La Princesa, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Derrame pleural tras tratamiento intravesical con bacilo de Calmette-Guérin" ] ] "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" => 887 "Ancho" => 995 "Tamanyo" => 78101 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Posteroanterior chest radiograph. Large right pleural effusion. Intracavitary pacemaker.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Intravesical instillation of bacillus Calmette-Guerin (BCG), a live attenuated strain of <span class="elsevierStyleItalic">Mycobacterium bovis</span>, has been shown in numerous studies to be an effective treatment for superficial <span class="elsevierStyleItalic">in situ</span> bladder cancer. However, this procedure is not free of complications.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a patient diagnosed with pleural effusion due to <span class="elsevierStyleItalic">M. bovis</span> after treatment with intravesical BCG instillation.</p><p id="par0015" class="elsevierStylePara elsevierViewall">This was an 85-year-old man, former smoker, with mild chronic obstructive pulmonary disease, atrial fibrillation, and pacemaker implantation due to sick sinus syndrome, diagnosed with multifocal transitional cell carcinoma of the bladder treated by transurethral resection and 6 BCG instillations. One year later, he presented in the emergency department with pleuritic chest pain and increased dyspnea. Chest radiograph (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) revealed right pleural effusion. Empirical antibiotic therapy began with amoxicillin/clavulanic acid and the patient was admitted to the respiratory medicine department for further examination with chest computed tomography (CT) and diagnostic thoracentesis. The CT revealed extensive right pleural effusion with passive atelectasis of the ipsilateral lower lobe, subpleural calcified granuloma in the left lower lobe, and prevascular and hilar lymphadenopathies, suggestive of a previous granulomatous process. Thoracentesis was performed, yielding cloudy pleural exudate with elevated adenosine deaminase (ADA) (63.9<span class="elsevierStyleHsp" style=""></span>U/l), and a predominance of mononuclear cells (85%). We did not perform a pleural biopsy due to the high probability that this was a <span class="elsevierStyleItalic">Mycobacterium</span> infection, given the characteristics of the pleural fluid. Culture of the fluid was positive for <span class="elsevierStyleItalic">M. bovis</span>, leading to a diagnosis of pleural effusion due to <span class="elsevierStyleItalic">M. bovis</span> caused by intravesical instillation of BCG. The patient was treated for 6 months with isoniazid, rifampicin, and ethambutol with good clinical response and resolution of the pleural effusion, with no adverse drug effects.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Although intravesical instillation of BCG is usually well tolerated, local (1%) and systemic (4.8%) complications have been described. Among the systemic events, pulmonary complications account for 1%–3% and 5 forms of presentation have been described: interstitial pneumonitis, empyema, diffuse alveolar damage, pneumonia with or without cavitation, and miliary tuberculosis (TB). The latter is the most common form of infection due to BCG in the literature and accounts for one third of cases.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1,2</span></a> Some authors argue that the underlying cause of systemic involvement is hypersensitivity to the BCG, while others believe that it is due to systemic dissemination after hematogenous seeding from the bladder.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">No evidence is available to show that prophylaxis with isoniazid protects against systemic dissemination after intravesical BCG administration.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> Complications may take months or even years to appear after the first instillation.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In our patient, culture was positive for <span class="elsevierStyleItalic">M. bovis</span>. The chest CT showed residual lesions suggestive of an old untreated TBC. Complications occur more often in patients with a history of TBC than in patients without previous tuberculous disease.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Our case was an unusual presentation of bacilli in the pleural fluid, prompting a diagnosis of pleural effusion due to BCG dissemination after intravesical instillation, 1 year after receiving this treatment. It is also uncommon for this complication to present as pleural effusion. We could only find 1 similar case of pleural effusion 6 years after administration of BCG treatment, although in that patient, no mycobacteria could be isolated from pleural fluid.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Roca Noval A. Derrame pleural tras tratamiento intravesical con bacilo de Calmette-Guérin. Arch Bronconeumol. 2017;53:694–695.</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" => 887 "Ancho" => 995 "Tamanyo" => 78101 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Posteroanterior chest radiograph. Large right pleural effusion. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 1 | 0 | 1 |
| 2024 October | 45 | 19 | 64 |
| 2024 September | 44 | 12 | 56 |
| 2024 August | 71 | 48 | 119 |
| 2024 July | 45 | 24 | 69 |
| 2024 June | 77 | 25 | 102 |
| 2024 May | 94 | 27 | 121 |
| 2024 April | 39 | 31 | 70 |
| 2024 March | 52 | 16 | 68 |
| 2024 February | 30 | 27 | 57 |
| 2023 March | 18 | 4 | 22 |
| 2023 February | 53 | 23 | 76 |
| 2023 January | 45 | 30 | 75 |
| 2022 December | 55 | 38 | 93 |
| 2022 November | 52 | 23 | 75 |
| 2022 October | 56 | 37 | 93 |
| 2022 September | 49 | 38 | 87 |
| 2022 August | 49 | 41 | 90 |
| 2022 July | 33 | 43 | 76 |
| 2022 June | 39 | 36 | 75 |
| 2022 May | 47 | 36 | 83 |
| 2022 April | 38 | 32 | 70 |
| 2022 March | 40 | 39 | 79 |
| 2022 February | 56 | 24 | 80 |
| 2022 January | 59 | 35 | 94 |
| 2021 December | 38 | 45 | 83 |
| 2021 November | 55 | 43 | 98 |
| 2021 October | 38 | 51 | 89 |
| 2021 September | 67 | 51 | 118 |
| 2021 August | 22 | 34 | 56 |
| 2021 July | 25 | 32 | 57 |
| 2021 June | 44 | 40 | 84 |
| 2021 May | 45 | 33 | 78 |
| 2021 April | 95 | 80 | 175 |
| 2021 March | 49 | 21 | 70 |
| 2021 February | 34 | 32 | 66 |
| 2021 January | 27 | 7 | 34 |
| 2020 December | 38 | 21 | 59 |
| 2020 November | 28 | 15 | 43 |
| 2020 October | 53 | 14 | 67 |
| 2020 September | 71 | 8 | 79 |
| 2020 August | 62 | 11 | 73 |
| 2020 July | 57 | 21 | 78 |
| 2020 June | 27 | 11 | 38 |
| 2020 May | 29 | 20 | 49 |
| 2020 April | 34 | 21 | 55 |
| 2020 March | 28 | 12 | 40 |
| 2020 February | 31 | 18 | 49 |
| 2020 January | 40 | 13 | 53 |
| 2019 December | 43 | 19 | 62 |
| 2019 November | 29 | 20 | 49 |
| 2019 October | 33 | 17 | 50 |
| 2019 September | 27 | 10 | 37 |
| 2019 August | 30 | 22 | 52 |
| 2019 July | 26 | 16 | 42 |
| 2019 June | 26 | 5 | 31 |
| 2019 May | 43 | 5 | 48 |
| 2019 April | 59 | 9 | 68 |
| 2019 March | 31 | 17 | 48 |
| 2019 February | 32 | 19 | 51 |
| 2019 January | 29 | 24 | 53 |
| 2018 December | 40 | 22 | 62 |
| 2018 November | 85 | 15 | 100 |
| 2018 October | 148 | 24 | 172 |
| 2018 September | 76 | 13 | 89 |
| 2018 May | 1 | 0 | 1 |
| 2018 April | 54 | 11 | 65 |
| 2018 March | 43 | 21 | 64 |
| 2018 January | 1 | 0 | 1 |
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