Elsevier

Annals of Vascular Surgery

Volume 59, August 2019, Pages 310.e7-310.e11
Annals of Vascular Surgery

Case Report
Ruptured Mycotic Aneurysm After Intravesical Instillation for Bladder Tumor

https://doi.org/10.1016/j.avsg.2018.12.100Get rights and content

Background

Intravesical instillation of Bacillus Calmette-Guérin (BCG) is an effective and widely used treatment for patients with in situ bladder cancer. Major complications are quite uncommon, but a systemic dissemination of the attenuated strain of Mycobacterium bovis is possible. Few cases of aortic rupture caused by M bovis infection are described in literature.

Methods

A 70-year-old male, treated 3 months before with BCG instillation, presented to the emergency department because of a ruptured abdominal aortic aneurysm. The patient was hemodynamically stable, with a "hostile" abdomen. Therefore, an Endologix AFX endograft was deployed. During the postoperative period, his blood inflammatory markers increased, suspicious of a graft infection. Single-photon emission computed tomography (CT)/CT scan showed aortic increased uptake. Antibiotic therapy was continued, but after some days, the patient presented with hematemesis, and the CT scan showed an aortoenteric fistula. In emergency, the infected graft and aneurysm were removed, enteric fistula was closed, and an axillobifemoral bypass was performed. The patient died 25 days after endovascular aneurysm repair explantation.

Results

Despite the high suspicion of mycotic aortic aneurysm and graft infection by M bovis, there is no proof of this theory because of the absence of any positive culture test. M bovis is a slow-growing bacteria, and specific culture tests are required to identify it; indeed, all our blood and intraoperative samples were positive to other bacteria, probably the contaminant ones.

Conclusions

Mycotic aneurysm is an extremely rare complication of intravesical BCG therapy, but it must be taken into consideration in patients with rapidly growing aortic aneurysms or rupture of a normal aorta, who have been previously submitted to this kind of instillation.

Section snippets

Case Report

A 70-year-old male, affected by hypertension, hyperlipidemia, and ischemic heart disease, presented to the emergency department with a history of lumbar pain radiating bilaterally to the back lasting from about 1 week. The patient's history showed subsequent transurethral resections (10 and 5 months before) and intravesical BCG therapy (3 months before) as treatment for bladder transitional cell carcinoma. Two months apart, due to biopsy-proven residual high-degree transitional papillary cell

Discussion

Intravesical BCG instillation therapy is the treatment of choice for early-stage transitional cell bladder cancer with reported cure rates of 70%.3 Although it is a well-tolerated treatment, systemic reactions such as fever, malaise, hepatitis, and pneumonia have been described.3, 4 Vascular complications such as mycotic aneurysms occur in less than 1% of cases.5 In literature, less than 30 cases of MB-related mycotic aneurysms are reported.6, 7 The presence of mycotic aneurysms, similar to

Cited by (0)

View full text