1. Systemic BCG with Pneumonitis By Carrie Fitzgerald Uro 1

2. Hospital day 3 Urology consult for patient with irritative symptoms R/O UTI 81 year old African American male, appears younger then stated age Presents with c/o irritative voiding sxs for 24 hr. daughter noticed diaphoresis acute change MS; dysuria, fever 103 brought pt to ER. Pt seen by medicine and started on empiric parenteral antibiotic treatment after urine culture obtained Found out 72 hours later patient was post BCG intravesical treatment, including dysuria and frequency and urology consult obtained PMHx Superficial Bladder Ca sp BCG 6 week induction; maintenance dose 72 hr prior; ho sxs post intraves CaP s/p RRP Dementia HTN Meds : Aricept, Cozaar, Enablex, HCTZ, Norvasc, Colace Soc Hx: Tob 30 pack yr, no ETOH, no illicits Fam Hx: no GU malignancies

3. Labs and Exam VS 100.2 82 22 154/86 96% AAOx2, NAD CTAB, S1S2 no murmurs Soft, NT no sp ttp, no CVA tenderness Uncircumsize. Nl Descended. Foley gravity, urine clear, yellow, no meatal erosion bld. Prostate absent. WBC 5.4 (13.5/ band % 13 on admit) H/H 11.4/32 12.9/36.4 on admit BUN 13 Cr 1.16 (35/2.47 on admission) AST 93 ALT 94 AlkP 92 T bili 2.26 D bili 1.18 Sterile pyruria (W 20- 50) CXR

4. Assessment and Plan Assessment: UTI vs BCG side effect vs systemic BCG Hyperpyrexia AKI Hyperbilirubinemia Anemia HTN Bld/U Tb cx ID consult Levaquin, INH WBC Scan Abd US CT scan abd/pel Renal cyst /abscess drainage

5. Results and PE Bld Cx : no growth 5 d Ucx : no growth 24 hrs Misc Cx : R renal cyst aspirate neg for AFB, aerobes, anaerobe Episodes of fever (Tmax 104.4) and diaphoresis Q8-12 hour Expiratory wheezes; O2 sat80% Rigors Change in MS

6. Hospital Day 13 Assessment Disseminated BCG +/- hypersensitivity rxtn Respiratory distress Hepatitis BCG vs Pharm Hyperpyrexia Anemia – AOCD w/folate def Urinary incontinence AKI HTN WBC 9.6 (11/band% 25 hosp day 17) H/H 8.3/24 (7.5/21.9 hosp 17) BUN 21 Cr 1.38 AST 162 ALT 78 AlkP 102 T bili 3.01 D bili 1.93 PSA < 0.01 HepB ab/Ag - neg

7. Treatment Rifampin 600 mg po Qd Pyrazinamide 1000 mg po Qd Isoniazid 300 mg po Qd Levaquin 250 mg po Qd Stopped Pyrazinamide on 10/27 started Ethambutol 1600mg po daily Zosyn 3.375 g x1 Vancomycin 750 mg x 1 Rocephin 1g x1 Azithromycin 500 mg x1

8. In Addition Lamm consult Started Solumedrol 40 mg IVP Q 6 hours hosp day 17 with slow taper Discharged to rehab hosp day 20