Abstract Details

Title Mycobacterial Meningitis as an Early Complication of Bacille Calmette-Guerin Intravesical Chemotherapy in the Setting of a Systemic Infection.

Topic Neuro-oncology

Presentation(s) P1 - Poster Session 1 (9:00 AM-5:00 PM)

Poster/Presentation
Number 415

Objective Intravesical BCG, a live-attenuated strain of mycobacterium is used as a treatment of bladder cancer. Severe complications such as pneumonitis or even death occur in <5% of patients. CNS manifestations are rare and usually present as a late complication of a prolonged BCG therapy. Here we present a case of mycobacterium tuberculous meningitis in the setting of coccidiomycosis mimicking leptomeningeal disease, presenting as an early complication after a short course of BCG therapy.

Background 80 y/o man with prostate and recurrent bladder cancer, s/p multiple surgeries including TURBT with intravesical BCG (last dose 1-week prior) complicated with fever and coccidiomycosis (on fluconazole) presented with a 2-week history of progressive gait unsteadiness with abrupt decline making him unable to walk for 3 days. On exam, he had preserved strength, but severe ataxia with LLE dysmetria and 3+DTRs. MRI-brain showed nodular leptomeningeal enhancement involving the cranial nerves, brainstem surface, superior cerebellum and a mass posterior to the internal carotid artery suggesting nodal metastasis. MRI-spine showed subtle abnormal thoracic leptomeningeal enhancement. LP showed elevated WBCs, protein(125) and decrease glucose(<30). TB-PCR, coccidioidomycosis Ag/Ab/PCR and cytology were negative. His gait continued to decline. LN biopsy negative for sarcoidosis. He was started on steroids. Since he did not improve on treatment for coccidiomycosis and steroids, empiric therapy for BCG was initiated. Patient and repeat MRI reported interval improvement. Repeat CSF demonstrated lymphocytic predominant leukocytosis (WBC-108), Glucose-52 and protein-72. It was positive for AFB on PCR and mycobacterium tuberculosis on culture. Therapy with rifampin/ethambutol/moxifloxacin was initiated with improvement in gait one year later. Exam displayed improved LUE dysmetria and BL LE hyperreflexia. Repeat MRI-brain/spine showed resolution of CNS changes.

Design/Methods N/A

Results N/A

Conclusions Secondary infectious leptomeningitis from BCG is a rare complication but should be considered when testing is negative for cancer or common causes of infectious meningitis or sarcoidosis.

Authors/Disclosures
Madiha Tariq, MD (Quinte Health Belleville General Hospital) PRESENTER	Dr. Tariq has received personal compensation for serving as an employee of SIU .
Nathan Clarke, MD (University of Michigan)	Dr. Clarke has nothing to disclose.
Merry Chen, MD (MD Anderson Cancer Center)	Dr. Chen has nothing to disclose.

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