rifampin and Carcinoma--Transitional-Cell

A 71-year-old male patient with a superficial transitional cell carcinoma of the urinary bladder developed high fever and jaundice, accompanied by progressively increasing serum aminotransferase activities, 2 weeks after the fourth local instillation with an attenuated live strain of Mycobacterium bovis [bacillus Calmette-Guérin (BCG)]. A liver biopsy showed non-caseating granulomatous hepatitis. Cultures for mycobacteria were negative. Mycobacterial DNA was not detected in liver tissue using the polymerase chain reaction. Empirical treatment with rifampicin and isoniazid was started, resulting in partial recovery. After 6 months of therapy, however, serum aminotransferase activities were still twice the upper limit of normal. A second liver biopsy still demonstrated several granulomas. Only after addition of prednisolone, liver tests completely normalized. Also histologically the lesions improved dramatically. This suggests that the BCG hepatitis was at least partially caused by a hypersensitivity reaction. Our patient is the first reported case of BCG hepatitis with histological follow-up under therapy.

Topics: Adjuvants, Immunologic; Administration, Intravesical; Aged; Antitubercular Agents; BCG Vaccine; Biopsy; Carcinoma, Transitional Cell; Drug Hypersensitivity; Drug Therapy, Combination; Hepatitis; Humans; Immunosuppressive Agents; Isoniazid; Liver; Male; Prednisolone; Rifampin; Transaminases; Treatment Outcome; Urinary Bladder Neoplasms

Topics: Aged, 80 and over; Antitubercular Agents; BCG Vaccine; Biopsy; Carcinoma, Transitional Cell; Diagnosis, Differential; Humans; Isoniazid; Male; Pleural Effusion; Rifampin; Risk Factors; Treatment Outcome; Urinary Bladder Neoplasms

Bacillus Calmette-Guérin (BCG) is a live attenuated strain of Mycobacterium bovis that has been widely used for the treatment of superficial transitional cell carcinoma of the bladder. We describe a rare case of supra-renal mycotic aortic aneurysm secondary to BCG instillation in a 75-year-old male. Patients presenting with systemic symptoms post-instillation, possibly with an aneurysm, should raise suspicion of BCG dissemination, which requires early instigation of anti-mycobacterial drugs.

Topics: Administration, Intravesical; Aged; Aneurysm, Infected; Antibiotics, Antitubercular; Aorta, Abdominal; Aortic Aneurysm, Abdominal; BCG Vaccine; Carcinoma, Transitional Cell; England; Ethambutol; Fatal Outcome; Humans; Isoniazid; Male; Mycobacterium bovis; Mycobacterium Infections; Rifampin; Tomography, X-Ray Computed; Urinary Bladder Neoplasms

A 71-year-old patient with a superficial carcinoma of the urinary bladder and high risk of recurrence was treated with intravesical instillation of Bacillus Calmette-Guérin (BCG) after transurethral resection. As a complication of the catheterization during BCG-instillation therapy the patient suffered from tuberculosis. The patient received a tuberculosis triple-therapy including rifampicin 600 mg once daily, isoniazid 300 mg once daily and ethambutol 400 mg thrice daily. The existing arterial hypertension had successfully been controlled by 3.75 mg bisoprolol medication once daily for the last 15 years. An increase of blood pressure and cardiac arrhythmia were seen after combining the β1-receptor blocker treatment with the triple-therapy.. The blood pressure was 160/90 mm Hg. The heart rate reflected a value of 98 beats per minute. In the resting ECG monotopic ventricular extrasystoles could be diagnosed.. The dosage of bisoprolol was changed to 3.75 mg in the morning and additional 1.875 mg in the evening. Due to this increase of dosage the blood pressure could be controlled sufficiently.. Rifampicin is one of the best known potent enzyme inducing drugs. It strongly induces the expression of cytochrome P450 3A4 in the liver. The enzyme induction enhance the hepatic bisoprolol metabolism, hence the metabolic clearance of the drug increased. The maximal plasma level of bisoprolol decrease and in our use the arterial hypertension could not be treated sufficiently. It is well known that half the dose of bisoprolol undergoes oxidative metabolism in the liver and the rest eliminated unchanged in the kidney. A dosage adjustment of bisoprolol is necessary if the clinical status of the patient requires treatment with the antituberculosis drug rifampicin.

Topics: Adjuvants, Immunologic; Administration, Intravesical; Aged; Antihypertensive Agents; Antitubercular Agents; BCG Vaccine; Bisoprolol; Blood Pressure; Carcinoma, Transitional Cell; Cardiac Complexes, Premature; Combined Modality Therapy; Cytochrome P-450 CYP3A; Dose-Response Relationship, Drug; Drug Administration Schedule; Drug Interactions; Drug Therapy, Combination; Electrocardiography; Enzyme Induction; Ethambutol; Humans; Isoniazid; Male; Metabolic Clearance Rate; Neoplasm Recurrence, Local; Rifampin; Tuberculosis, Urogenital; Urinary Bladder Diseases; Urinary Bladder Neoplasms

A 71-year-old patient with a superficial carcinoma of the urinary bladder and high risk of recurrence was treated with intravesical instillation of Bacillus Calmette-Guérin (BCG) after transurethral resection. As a complication of the catheterization during BCG-instillation therapy the patient suffered from tuberculosis. The patient received a tuberculosis triple-therapy including rifampicin 600 mg once daily, isoniazid 300 mg once daily and ethambutol 400 mg thrice daily. The existing arterial hypertension had successfully been controlled by 3.75 mg bisoprolol medication once daily for the last 15  years. An increase of blood pressure and cardiac arrhythmia were seen after combining the β (1)-receptor blocker treatment with the triple-therapy.. The blood pressure was 160 / 90 mmHg. The heart rate reflected a value of 98  beats per minute. In the resting ECG monotopic ventricular extrasystoles could be diagnosed.. The dosage of bisoprolol was changed to 3.75 mg in the morning and additional 1.875 mg in the evening. Due to this increase of dosage the blood pressure could be controlled sufficiently.. Rifampicin is one of the best known potent enzyme inducing drugs. It strongly induces the expression of cytochrome P450 3A4 in the liver. The enzyme induction enhance the hepatic bisoprolol metabolism, hence the metabolic clearance of the drug increased. The maximal plasma level of bisoprolol decrease and in our use the arterial hypertension could not be treated sufficiently. It is well known that half the dose of bisoprolol undergoes oxidative metabolism in the liver and the rest eliminated unchanged in the kidney. A dosage adjustment of bisoprolol is necessary if the clinical status of the patient requires treatment with the antituberculosis drug rifampicin.

Topics: Aged; Antihypertensive Agents; Antitubercular Agents; BCG Vaccine; Bisoprolol; Carcinoma, Transitional Cell; Chemotherapy, Adjuvant; Combined Modality Therapy; Cytochrome P-450 CYP3A; Dose-Response Relationship, Drug; Drug Administration Schedule; Drug Interactions; Drug Therapy, Combination; Enzyme Induction; Humans; Hypertension; Male; Rifampin; Tuberculosis, Urogenital; Urinary Bladder Diseases; Urinary Bladder Neoplasms

We describe a case of bilateral tuberculous epididymitis that occurred two weeks after intravesical Bacillus Calmette-Guerin (BCG) instillation. A 72-year-old man received transuretheral resection of bladder transitional cell carcinoma in November 2000. Although he had no recurrence for about 4 years, cystoscopy revealed small papillary tumors in the bladder in September 2004. A course of 8 weekly intravesical instillations of BCG was started. After the second BCG instillation (160 mg) he had bilateral painful scrotal swelling. Although he was administered isoniazid (INH) and rifampicin (RFP), scrotal swelling got worse. Right orchiectomy and left epididymectomy was performed in December 2004. Histological diagnosis was bilateral tuberculous epididymitis. Postoperatively, he was administered INH and RFP and had no recurrence for 3 months.

Topics: Administration, Intravesical; Aged; Antitubercular Agents; BCG Vaccine; Carcinoma, Transitional Cell; Combined Modality Therapy; Drug Therapy, Combination; Epididymitis; Humans; Isoniazid; Male; Orchiectomy; Rifampin; Tuberculosis, Male Genital; Urinary Bladder Neoplasms

Intravesical bacillus Calmette-Guerin (BCG) is widely used in the management of bladder cancer but because it is a living organism, local and disseminated infection may result.. A prospective assessment of complications of this therapy in 200 patients in Queensland was performed. A review of management of complications of intravesical BCG was also carried out.. Major side effects were rare. Cystitis was the most common side effect, being seen to some degree in all patients, although only forcing cessation of BCG therapy in two patients. Two patients developed persistent cystitis necessitating institution of isoniazid and rifampicin. Two patients had culture-proven bladder infection that presented several months after the BCG treatment. These patients also responded to two-drug antituberculous therapy. While low-grade fever is very common with this therapy, seven patients (3.5%) had fevers of > 39 degrees C within 48 h of receiving BCG. Fevers may be an indication of severe disseminated mycobacterial infection, which has a high mortality, so it needs to be treated aggressively. Alternatively bacterial sepsis with gram-negative bacterial pathogens or a hypersensitivity reaction to BCG may cause this degree of fever, and cannot be rapidly distinguished from fulminant mycobacterial infection. One patient in the present series developed pneumonia attributed to mycobacterial dissemination.. The key to appropriate management of complications of BCG therapy is awareness of their possibility, even months or years after the therapy has been given. Appropriate empirical therapy in acute situations and mycobacterial culture in chronic situations can then be performed.

Topics: Administration, Intravesical; Aged; Aged, 80 and over; Amoxicillin; Antitubercular Agents; BCG Vaccine; Carcinoma, Transitional Cell; Cystitis; Drug Therapy, Combination; Female; Fever; Gentamicins; Humans; Immunotherapy; Isoniazid; Male; Middle Aged; Prospective Studies; Rifampin; Urinary Bladder Neoplasms; Urinary Tract Infections

Among 169 patients treated for supeficial bladder tumor with 150 mg Pasteur-strain bacillus Calmette-Guérin (BCG) intravesical instillation, 5 cases of 'BCGitis' were observed, i.e. a severe systemic BCG infection with bronchopulmonary lesions and granulomatous hepatitis. In 4 cases, the complications appeared at the early stage of treatment (after the 3rd, 6th, 6th and 8th instillations, respectively). In 1 case, treated with monthly maintenance therapy for 2 years, BCGitis appeared 6 months after treatment had been completed and, in addition to pulmonary basal infiltrate and granulomatous hepatitis, intramedullary granulomatosis was observed. In 3 patients, trauma must be taken into consideration as BCGitis appeared after traumatic instillation with bleeding. All patients were cured by treatment with rifampicin, isoniazid and prednisone.

Topics: Administration, Intravesical; Aged; BCG Vaccine; Carcinoma, Transitional Cell; Humans; Isoniazid; Male; Prednisolone; Rifampin; Time Factors; Tuberculosis; Urinary Bladder Neoplasms