Case and Research Letters
Granulomatous Balanitis After Intravesical Bacille Calmette-Guérin Instillation
Balanitis granulomatosa tras terapia intravesical con bacilo de Calmette-Guérin
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A propósito de 2 casos" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1197 "Ancho" => 1608 "Tamanyo" => 195844 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A and B, The first patient presented several blue-gray macules on the dorsum of the fourth finger of the right hand and on the palmar surface of the fifth finger of the right hand. C, Dermoscopy revealed a homogeneous blue-gray pattern. D, The second patient presented similar lesions on the dorsum of both hands.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Garcias-Ladaria, P. Hernandez-Bel, J.L. Torregrosa-Calatayud, A. 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García Baldoví, M. Pérez-Crespo, J. Onrubia, M. Moragón" "autores" => array:4 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "García Baldoví" "email" => array:1 [ 0 => "maria_gbaldovi@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Pérez-Crespo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "J." "apellidos" => "Onrubia" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "M." "apellidos" => "Moragón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento de Dermatología, Hospital Clínico de San Juan de Alicante, Alicante, Spain" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Dermatología Patológica, Hospital Clínico de San Juan de Alicante, Alicante, Spain" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Balanitis granulomatosa tras terapia intravesical con bacilo de Calmette-Guérin" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 887 "Ancho" => 1335 "Tamanyo" => 159251 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Marked regression of the papular lesions after 2 weeks of treatment.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Transitional cell carcinoma of the bladder is an aggressive tumor with a high potential for malignant progression. Bacille Calmette-Guérin (BCG) has been used to treat malignant diseases for more than 20 years, and bladder cancer has been treated with it longer, since 1976.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> BCG is an attenuated strain of <span class="elsevierStyleItalic">Mycobacterium bovis</span>; instilled in solution to treat bladder cancer, it delays recurrence and prevents the implantation of tumor cells.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> Most patients tolerate intravesical irrigation with BCG well, but complications are not unusual. Side effects consist mainly of local irritation and flu-like symptoms and are usually mild. Various systemic and local infections have also been reported following instillation of BCG, which is a live organism. Such infections have included pneumonitis, hepatitis, granulomatous prostatitis, epididymitis, and renal parenchymal abscess.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4,6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present a case of granulomatous balanoposthitis that followed intravesical BCG therapy to prevent recurrence after transurethral resection of a transitional cell carcinoma.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 40-year-old man received intermittent cycles of intravesical BCG therapy to treat transitional cell carcinoma of the bladder starting in 2009. At 48<span class="elsevierStyleHsp" style=""></span>hours from the sixth instillation, which involved a difficult catheterization with slight extravasation of the product, the patient presented with yellowish papular lesions on the glans penis, large painful lymph nodes in the right groin, and dysuria (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). A biopsy was performed and cultures were ordered. In the differential diagnosis, we considered infectious diseases (herpetic primo-infection, syphilis, fungal infection, skin infection due to BCG) and neutrophilic diseases (pyoderma gangrenosum, Behçet disease).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Histology showed a substantial neutrophilic infiltrate in the dermis with no granulomas or multinucleated giant cells (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Ziehl-Neelsen and periodic acid-Schiff staining were negative for micro-organisms. The culture, which was negative for fungi, grew only <span class="elsevierStyleItalic">Streptococcus salivarius</span> (a saprophyte). Despite the negative results of the acid-fast staining, BCG infection was suspected because the other candidate diagnoses were unlikely. Empirical treatment with isoniazid and rifampicin was ordered and by 15 days had reduced the spread of the lesions. At this time, isoniazid-resistant <span class="elsevierStyleItalic">M bovis</span> was isolated in the initial culture in Lowenstein medium. Rifampicin, ethambutol, and moxifloxacin were then prescribed and the lesions had improved considerably after 2 weeks of treatment (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Intravesical BCG treatment is recognized as an effective therapy for superficial bladder cancer, although numerous side effects have been reported.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The most common reactions are minor and include cystitis, hematuria, low-grade fever, general malaise, and nausea. More serious side effects include fever, granulomatous pneumonitis, hepatitis, renal abscess, and even fatal sepsis.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3,7</span></a> Granulomatous reactions associated with BCG therapy can occur in the bladder, epididymis, prostate, kidney, lungs, and liver. However, involvement of the glans penis and urethra is quite rare: only 12 cases have been reported to date.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,8</span></a> In each case, pathology showed granulomas and, usually, caseating necrosis. These findings were not present in our patient, perhaps because the biopsy was performed promptly.</p><p id="par0030" class="elsevierStylePara elsevierViewall">A recently published study showed that polymorphonuclear cells play an essential role in the antitumor effect of BCG treatment. Instillation of BCG starts a primarily neutrophilic inflammatory reaction that triggers the migration of effector cells (lymphocytes and monocytes or macrophages) to the bladder.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Patients who are immunocompromised, have mucosal barrier disruption due to injury, or have positive reactions on tuberculin skin testing are at higher risk of presenting BCG side effects.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4,6,7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Given the small number of published cases, no standard treatment has emerged. Some reviews recommend starting the treatment of prostatitis and granulomatous orchiepididymitis with 300<span class="elsevierStyleHsp" style=""></span>mg of oral isoniazid and 600<span class="elsevierStyleHsp" style=""></span>mg of rifampicin and continuing it for 3 to 6 months while discontinuing BCG therapy and testing for antibiotic resistance.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,7</span></a> Other authors recommend corticosteroid therapy at the start of treatment.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">This rare case of balanitis due to BCG demonstrates the need to consider this possible side effect when patients are undergoing BCG therapy.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: García Baldoví M, et al. Balanitis granulomatosa tras terapia intravesical con bacilo de Calmette- Guérin. Actas Dermosifiliogr. 2013;104:251–2.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1000 "Ancho" => 1335 "Tamanyo" => 167936 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Yellowish papules on the glans penis 48<span class="elsevierStyleHsp" style=""></span>hours after the sixth instillation of bacille Calmette-Guérin.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1230 "Ancho" => 1665 "Tamanyo" => 439557 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Significant neutrophilic infiltrate in the dermis with no granulomas or multinucleated giant cells. Hematoxylin-eosin, original magnification ×40.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 887 "Ancho" => 1335 "Tamanyo" => 159251 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Marked regression of the papular lesions after 2 weeks of treatment.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Disseminated <span class="elsevierStyleItalic">Mycobacterium bovis</span> after intravesicular bacillus Calmette-Guerin treatments for bladder cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 11 | 20 |
| 2024 October | 64 | 63 | 127 |
| 2024 September | 64 | 36 | 100 |
| 2024 August | 85 | 84 | 169 |
| 2024 July | 72 | 53 | 125 |
| 2024 June | 83 | 56 | 139 |
| 2024 May | 63 | 45 | 108 |
| 2024 April | 63 | 30 | 93 |
| 2024 March | 56 | 44 | 100 |
| 2024 February | 48 | 40 | 88 |
| 2024 January | 42 | 50 | 92 |
| 2023 December | 57 | 34 | 91 |
| 2023 November | 60 | 33 | 93 |
| 2023 October | 44 | 24 | 68 |
| 2023 September | 56 | 28 | 84 |
| 2023 August | 26 | 22 | 48 |
| 2023 July | 33 | 48 | 81 |
| 2023 June | 51 | 44 | 95 |
| 2023 May | 30 | 31 | 61 |
| 2023 April | 36 | 24 | 60 |
| 2023 March | 35 | 28 | 63 |
| 2023 February | 21 | 23 | 44 |
| 2023 January | 25 | 50 | 75 |
| 2022 December | 49 | 41 | 90 |
| 2022 November | 18 | 24 | 42 |
| 2022 October | 14 | 25 | 39 |
| 2022 September | 25 | 30 | 55 |
| 2022 August | 24 | 39 | 63 |
| 2022 July | 23 | 37 | 60 |
| 2022 June | 19 | 23 | 42 |
| 2022 May | 23 | 27 | 50 |
| 2022 April | 40 | 26 | 66 |
| 2022 March | 41 | 46 | 87 |
| 2022 February | 38 | 32 | 70 |
| 2022 January | 23 | 29 | 52 |
| 2021 December | 26 | 44 | 70 |
| 2021 November | 45 | 42 | 87 |
| 2021 October | 36 | 62 | 98 |
| 2021 September | 29 | 50 | 79 |
| 2021 August | 43 | 21 | 64 |
| 2021 July | 33 | 46 | 79 |
| 2021 June | 35 | 29 | 64 |
| 2021 May | 25 | 39 | 64 |
| 2021 April | 45 | 56 | 101 |
| 2021 March | 53 | 32 | 85 |
| 2021 February | 47 | 38 | 85 |
| 2021 January | 31 | 23 | 54 |
| 2020 December | 22 | 14 | 36 |
| 2020 November | 34 | 20 | 54 |
| 2020 October | 20 | 20 | 40 |
| 2020 September | 26 | 14 | 40 |
| 2020 August | 19 | 25 | 44 |
| 2020 July | 24 | 19 | 43 |
| 2020 June | 28 | 18 | 46 |
| 2020 May | 28 | 14 | 42 |
| 2020 April | 22 | 20 | 42 |
| 2020 March | 28 | 18 | 46 |
| 2020 February | 4 | 4 | 8 |
| 2020 January | 0 | 2 | 2 |
| 2019 December | 0 | 3 | 3 |
| 2019 October | 0 | 3 | 3 |
| 2019 September | 0 | 1 | 1 |
| 2019 July | 0 | 1 | 1 |
| 2019 May | 0 | 15 | 15 |
| 2019 April | 0 | 2 | 2 |
| 2019 March | 0 | 7 | 7 |
| 2019 January | 1 | 0 | 1 |
| 2018 November | 1 | 0 | 1 |
| 2018 October | 1 | 0 | 1 |
| 2018 September | 4 | 0 | 4 |
| 2018 April | 0 | 1 | 1 |
| 2018 March | 5 | 2 | 7 |
| 2018 February | 24 | 7 | 31 |
| 2018 January | 36 | 8 | 44 |
| 2017 December | 34 | 15 | 49 |
| 2017 November | 31 | 8 | 39 |
| 2017 October | 37 | 5 | 42 |
| 2017 September | 29 | 9 | 38 |
| 2017 August | 31 | 16 | 47 |
| 2017 July | 25 | 11 | 36 |
| 2017 June | 42 | 15 | 57 |
| 2017 May | 31 | 5 | 36 |
| 2017 April | 40 | 9 | 49 |
| 2017 March | 28 | 29 | 57 |
| 2017 February | 26 | 7 | 33 |
| 2017 January | 45 | 16 | 61 |
| 2016 December | 72 | 3 | 75 |
| 2016 November | 64 | 3 | 67 |
| 2016 October | 81 | 27 | 108 |
| 2016 September | 85 | 9 | 94 |
| 2016 August | 68 | 7 | 75 |
| 2016 July | 50 | 6 | 56 |
| 2016 June | 10 | 9 | 19 |
| 2016 May | 6 | 3 | 9 |
| 2016 April | 5 | 31 | 36 |
| 2016 March | 3 | 12 | 15 |
| 2016 February | 4 | 13 | 17 |
| 2016 January | 7 | 8 | 15 |
| 2015 December | 4 | 8 | 12 |
| 2015 November | 11 | 6 | 17 |
| 2015 October | 7 | 4 | 11 |
| 2015 September | 5 | 2 | 7 |
| 2015 August | 9 | 5 | 14 |
| 2015 July | 297 | 119 | 416 |
| 2015 June | 242 | 7 | 249 |
| 2015 May | 288 | 19 | 307 |
| 2015 April | 281 | 15 | 296 |
| 2015 March | 276 | 3 | 279 |
| 2015 February | 222 | 2 | 224 |
| 2015 January | 190 | 6 | 196 |
| 2014 December | 157 | 5 | 162 |
| 2014 November | 141 | 4 | 145 |
| 2014 October | 200 | 7 | 207 |
| 2014 September | 142 | 2 | 144 |
| 2014 August | 131 | 4 | 135 |
| 2014 July | 138 | 6 | 144 |
| 2014 June | 145 | 8 | 153 |
| 2014 May | 169 | 8 | 177 |
| 2014 April | 162 | 3 | 165 |
| 2014 March | 155 | 14 | 169 |
| 2014 February | 171 | 7 | 178 |
| 2014 January | 131 | 4 | 135 |
| 2013 December | 105 | 9 | 114 |
| 2013 November | 134 | 7 | 141 |
| 2013 October | 107 | 5 | 112 |
| 2013 September | 59 | 4 | 63 |
| 2013 August | 59 | 6 | 65 |
| 2013 July | 15 | 5 | 20 |
| 2013 June | 4 | 2 | 6 |
| 2013 May | 4 | 5 | 9 |
| 2013 April | 2 | 0 | 2 |
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