Elsevier

Joint Bone Spine

Volume 73, Issue 1, January 2006, Pages 24-28
Joint Bone Spine

Review
Osteoarticular side effects of BCG therapy

https://doi.org/10.1016/j.jbspin.2004.12.003Get rights and content

Abstract

Although osteoarticular side effects of the Bacillus Calmette-Guérin (BCG) are rare compared to the number of administrations, BCG vaccination and cancer therapy are so widely used that the absolute number of cases is not negligible. Osteoarticular infection is an exceedingly rare complication of vaccination with the BCG. Intravesical BCG instillations used to treat superficial bladder cancer may cause arthralgia, reactive arthritis or osteoarticular infections. Intradermal BCG therapy used to treat a number of malignancies can cause osteoarticular infections or bilateral symmetric polyarthritis predominating in the wrists and fingers. In practice, when intravesical BCG instillation is followed by arthritis, hyperthermia is unhelpful for distinguishing septic arthritis from reactive arthritis. Arguments pointing to reactive arthritis include oligo- or polyarticular involvement and onset a few weeks (as opposed to a few months) after the last instillation. Nevertheless, joint fluid examination is in order to rule out septic arthritis. BCG-induced reactive arthritis usually responds well to nonsteroidal anti-inflammatory drugs. Osteoarticular infections related to BCG therapy should be treated by rifampin, isoniazid and ethambutol for 2 months, followed by rifampin and isoniazid for 10 months.

Section snippets

Osteoarticular side effects of BCG vaccination

Side effects of BCG vaccination are extremely uncommon. In a study of 5.5 million children vaccinated with the BCG in six European countries, the rates of locoregional and systemic side effects were 0.17‰ and 2.8 cases per million, respectively [1]. Systemic side effects consist of dissemination to an organ (bone, joint, liver and meninges) via the lymphatic circulation or bloodstream and of systemic miliary, an exceedingly rare complication seen only in immunocompromised individuals. M. bovis

Noninfectious side effects

Several studies indicate that the rate of osteoarticular side effects after intravesical BCG therapy ranges from 0.5% to 1% [16], [17]. Arthralgia is the most common pattern. There have been 43 reports of aseptic arthritis [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49], [50], [51], [52], [53], of which the main features are listed in Table 1.

Osteoarticular side effects of intradermal BCG therapy

Intradermal BCG therapy is used to treat a number of malignancies (melanoma, gastric cancer, colorectal cancer and lung cancer). Noninfectious arthritis has been reported by Torisu et al. [70]. Of 159 treated patients, 10 had bilateral symmetric polyarthritis selectively involving the wrists and fingers. The symptoms worsened at each BCG injection but resolved partially or completely with NSAID therapy. All 10 patients had a strong BCG response as assessed by peripheral lymphocyte proliferation

Conclusion

Osteoarticular side effects of BCG administration are uncommon. M. bovis infection may develop after vaccination or after intravesical or intradermal BCG therapy. Noninfectious joint involvement patterns differ according to the route of administration: polyarthritis predominating in the lower limbs and resembling reactive arthritis is the typical picture after intravesical instillation, whereas symmetric polyarthritis selectively affecting the wrists and fingers occurs after intradermal BCG

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