個案報告：卡介苗膀胱灌注引發之睪丸分枝桿菌感染

陳柏翰¹、張奐光¹

¹台灣基督長老教會馬偕醫療財團法人馬偕紀念醫院 泌尿科

Post-intravesical BCG mycobacterial orchitis: a case report

Bo-Han Chen¹, Huang-Kuang Chang¹

Department of Urology, MacKay Memorial Hospital, Taipei, Taiwan¹

Background

            Intravesical Bacillus Calmette-Guérin (BCG) was commonly used as an adjuvant therapy after transurethral resection of bladder tumor (TURBT). BCG could prevent bladder tumor from recurrence and progression with the help of T-helper cell type 1, which was regulated by IFN-γ, IL-2, and IL-12. However, there were several absolutely contraindication to BCG instillation, including immunocompromised status, immediately after TURBT, personal history of BCG sepsis, gross hematuria, traumatic catheterization and total incontinence. Here, we share a case of testicular mycobacterial infection after BCG treatment.

Case presentation

               A 72-year-old man came to our emergency room with the chief complaint of left scrotal pain and enlargement for 1 month. He had history of bladder urothelial carcinoma, T1, high grade. He had experienced laser TURBT for 1 time and following BCG for 7 times. The treatment finished 1.5 years ago. Cystoscopy showed no tumor recurrence. He presented left scrotal pain without fever and shock. Neither tachycardia nor hypotension were noted. Scrotal echogram found: suspect left scrotal abscess testis tumor. Further computed tomography scan showed multilobulated cystic lesion with wall enhancement in left scrotum (Figure 1). It was highly suspected testicular or scrotal abscess. Under the impression of left scrotal abscess, he was admitted for left orchiectomy.

               Microscopically, the testis and paratesticular soft tissue revealed heavy acute and chronic inflammatory infiltration. Necrotic areas were seen in the paratesticular soft tissue. The picture wass consistent with abscess. The testicular parenchyma revealed atrophic change with diminished spermatogenesis. There were ill-formed granuloma in the fibrotic background, composed of epithelioid histiocytes and focal multinucleated giant cells. Acid-fast stain showed: 1-9 acid fast bacilli/100 Fields (1000X). Tuberculosis polymerase chain reaction showed medium positive. The picture was compatible with Mycobacterial infection.

               The patient was discharged from hospital without complications 2 days postoperatively. Oral form rifampicin and ethambutol were prescribed for further treatment.

Discussion and conclusion

            BCG related complication were documented by several studies. The severity varied from disseminated BCG infection to local infection. Genitourinary tuberculosis complicates 0.9% of patients receiving BCG irrigation. [1] The involvement include pyelonephritis, renal abscesses, ureteric obstruction, cystitis, prostatitis, and epididymo-orchitis. When dealing with patient with history of BCG instillation, post BCG tuberculosis infection should be highly suspected.