Liver failure occurring as part of systemic BCG sepsis

Introduction: Local BCG installation increases T-cell immunoresponse and therefore postoperative intravesical BCG installation is used to prevent the reoccurrence of bladder cancer. The treatment is well tolerated in 95% of the patients, 5% of them develop local and systemic symptoms, and in 0.5% of the cases a life threatening BCG sepsis occurs. Case study: A 63-year old man underwent laser therapy followed by local BCG installation due to bladder cancer. He was hospitalised after the 5th installation session with high fever. As thorough investigations could not detect any other possible cause, a systemic BCG reaction was assumed. Despite the initiation of a combined antibiotic and antituberculotic therapy, his septic fever persisted and his synthetic liver functions deteriorated. He was transferred to our department in a frail health state with high fever, pulmonary infiltrate and the symptoms of liver failure. Negative serology and bacteriology tests excluded infectious hepatitis and further supported a systemic BCG reaction as the underlying reason of the multiple organ symptoms. Although the very limited available literature recommends giving a combination of triple antituberculotic agents (isonicid, rifampicin and ethambutol) and steroid as the treatment of systemic BCG reaction, we did not continue with the earlier antituberculotic therapy due to its well-known hepatotoxicity. Instead, antibiotic was initiated in combination with steroid, UDCA and supportive therapy of the liver functions. Consequent liver biopsy confirmed a granulomatous hepatitis. One month later the patient became afebrile and his liver functions normalised. Discussion: According to the limited available literature, systemic BCG sepsis should be treated with a combination of triple antituberculotic agents and steroid. There is, however, no recommendation on the therapeutic protocol when severe liver damage dominates the multiple organ symptoms. Our case study suggests that antituberculotic agents can be more harmful than beneficial in these cases and instead, a combination of antibiotic, steroid, bile acid and supportive therapy could be life saving.