Acute Diffuse Alveolar Hemorrhage following Intravesical Bacille Calmette-Guérin Immunotherapy for Superficial Bladder Cancer.

We report a case of a 80-year-old man who presented to our emergency department for high fever (39°C), hematuria and dys- pnea four hours after intravesicaladministration of Calmette-Guérin bacille (BCG) for a superficial bladder cancer. The patient already underwent two cycles of instillation. He developed hypoxemic respiratory failure with diffuse alveolitis at chest CT scan. Leukocyte count was 2.93 x 109/L, liver function test revealed aspartate aminotransferase 189U/L (15-37 U/L) and alanine ami- notransferase 113 U/L (30-65 U/L). Search for Legionella and pneumococcal urinary antigen and sputum staining for Mycobac- terium Tubercolosis were negative. A bronchoscopy revealed diffuse alveolar hemorrhage. The analysis of the bronchoalveolar lavage (BAL) fluid was negative for Mycobacterial species, pneumocystis jirovecii, and other bacterial and viral infection. The nasopharingeal swab for H1N1 was negative as well as results of galactomannan in serum and BAL. Empiric antibiotic treat- ment was started with no benefits. There was a rapid and significant clinical and radiological improvement with pulsed bolus of steroids and i.v. Immunoglobulins. A control of the computed tomography of the chest revealed multiple ground-glass opacities on both lung fields. Search for autoantibodies (i.e. ANCA, GBM) turned negative as well as BAL cytology. We supposed that a diagnosis of hypersensitivity interstitial pneumonitis with haemorrhagic alveolitis was the most fitting with the clinical picture. In literature there are few reports on hypersensitivity pneumonitis (HP) following intravesical instillation of BCG and none with haemorrhagic alveolitis. HP is explained by a hypersensitivity phenomenon following, usually, traumatic instillation of BCG. Hypersensitivity pneumonitis (HP) is a rare immunologically mediated lung disease caused by repeated exposition of organic antigens and should be considered in patients with acute respiratory symptoms with onset soon after immunotherapy with BCG.