BERKELEY, CA (UroToday.com) - Local immunotherapy with intravesical instillations of bacillus Calmette-Guérin (BCG) has been in use for the past 36 years in patients with intermediate- and high-grade superficial bladder carcinoma, having been demonstrated to be safe and effective. Its immunomodulatory activity is mainly local, but systemic side effects have been reported such as malaise and fever in up to 5% of patients, arthralgia at 1-5%, and arthritis in 0.5-1% of patients.[1,2]
Musculoskeletal side effects are infrequent taking into account the number of patients, and then reducing to case reports and small series. One of the major revisions is the one of Tinazzi et al., that assessed 48 publications with a total of 61 cases of autoimmune manifestations related to the administration of intravesical BCG. They found arthralgia and/or arthritis in 64% of patients, Reactive arthritis (ReA) in 24%, arthritis and fever in 4%, peripheral arthritis in patients with ankylosing spondylitis in 4%, psoriatic arthritis in 2%, and Sjögren's syndrome in 2%.
The secondary ReA after BCG usually appears as an asymmetric and additive arthritis, with fever in more than half of the cases, and occasionally associated with dactylitis, uveitis and urethritis. It is more common in men aged 50 to 60 years, with HLA B27 haplotype, and frequently presents after the fourth or fifth instillation. As additional evidence, there is usually a moderate increase in acute phase reactants in blood tests, joint fluid is predominantly inflammatory with prevalence of polymorphonuclear cells, and cultivation of mycobacteria in joint fluid, urine and blood is negative (excluding the possibility of septic arthritis BCG that has also been described).
Most patients respond favorably after withdrawing from treatment, and only a small percentage may require NSAIDs, corticosteroids, or rarely immunosuppressants such as methotrexate. It has also been suggested the use of tuberculostatics as isoniazid is for short periods of time is beneficial.
In conclusion, while the development of ReA following intravesical BCG is not a common event, it should be considered given the ease of diagnosis and the favorable treatment outcomes.
- Tinazzi E, Ficarra V, Simeoni S, Artibani W, Lunardi C. Reactive arthritis following BCG immunotherapy for urinary bladder carcinoma: a systematic review. Rheumatol Int. 2006;26:481–8. 2.
- Lamm DL, Van der Meijden PM, Morales A, Brosman SA, Catalona WJ, Herr HW, et al. Incidence and treatment of bacillus Calmette-Guerin intravesical therapy in superficial bladder cancer. J Urol. 1992;147:596–600.
- Macía Villa C, Sifuentes Giraldo W, Boteanu A, González Lanza M, Bachiller Corral J. Reactive arthritis after the intravesical instillation of BCG. Reumatol Clin. 2012 Feb 27.
- Neumayr C, Kirchgatterer A, Knoflach P. Chronic reactive arthritis associated with Calmette-Guérin bacillus. Dtsch Med Wochenschr. 2002;127: 1886–8.
Cristina Clara Macía Villa and Walter Alberto Sifuentes Giraldo as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
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