Case Report Eosinophilic Cystitis Induced by Bacillus Calmette-Guerin (BCG) Intravesical Instillation Adnen Hidoussi, Adel Slama, Mehdi Jaidane, Walid Zakhama, Anis Youssef, Nabil Ben Sorba, and Ali F. Mosbah Eosinophilic cystitis is a rare and uncommon inflammatory bladder disease, in which the pathophysiology is unclear; only a few cases of such disease induced by intravesical instillations have been described. We report a case of eosinophilic cystitis after intravesical bacillus Calmette-Guerin (BCG) instillation for nonmuscle-invasive transitional cell carcinoma of the bladder. To our knowledge, this report is the first case of eosinophilic cystitis induced by intravesical BCG therapy. UROLOGY 70: 591.e9 –591.e10, 2007. © 2007 Elsevier Inc. E osinophilic cystitis is a rare and uncommon inflam- matory bladder disease, in which the pathophysi- ology is unclear. Since its initial description in 1960 by Brown, 1 only a few cases occurring after intra- vesical instillations have been described. We report a case of eosinophilic cystitis presenting as a bladder tumor after a treatment with intravesical bacillus Calmette-Guerin (BCG) instillation for nonmuscle-inva- sive transitional cell carcinoma of the bladder. To our knowledge, this report is the first case of eosinophilic cystitis induced by intravesical BCG therapy. CASE PRESENTATION AND MANAGEMENT A 65-year-old woman presented a grade 1 stage pT1 transitional cell carcinoma of the bladder proved by transurethral resection. A regimen of intravesical BCG therapy was started with attenuated mycobacterium bovis (Pasteur 1173P2 strain) at 75 mg once a week for 6 weeks. After 6 weeks of BCG therapy, the patient noted reappearance of he- maturia and supra pubic pain with urinary frequency. Physical examination was unremarkable, urinalysis showed no infection, whereas renal and bladder ultrasound revealed a severely thickened bladder wall and bilateral hydrouret- eronephrosis caused by ureteric obstruction; renal func- tion was normal. Computerized tomography confirmed a thick bladder wall (Fig. 1). Because of the persistence of these severe symptoms, cystoscopy was performed, which showed diffuse thick- ening of the bladder wall with polypoid red lesions in- volving the ureteral orifices. Transurethral resection of the bladder wall was performed; superficial and deep sections of tissue were obtained. The histologic examination revealed the presence of abundant eosinophilic infiltrate, which is consistent with the diagnosis of eosinophilic cystitis. There was no evi- dence of transitional cell carcinoma (Fig. 2). The patient’s white blood cell count was 13,100/mm 3 with increased eosinophil count (5, 6% [normal, less than 3%]) and high level of immunoglobulin E (Ig E = 1,750 UI/mL). At the time of presentation, the patient had not re- ceived new medications and had no known drug allergies. Bilateral percutaneous nephrostomy (PCN) was per- formed; the patient was treated with 6 weeks of tapered prednisone starting at 20 mg. After 3 weeks, the patient had improvement of symptoms. The ultrasonography revealed significant improvement in her bladder wall thickening and the PCN was removed. At the end of treatment, preoperative symptoms were resolved and the ultrasonography was normal. COMMENT Eosinophilic cystitis is a rare and poorly understood form of allergic cystitis. Factors such as food allergens, para- sites, and drugs have been implicated in the genesis of eosinophilic cystitis. Acute eosinophilic cystitis after intravesical instilla- tions, such as mitomycin 2 or thiotepa 3 for treatment of superficial bladder cancer, and dimethyl sulfoxide 4 (DMSO) for treatment of interstitial cystitis, have been documented. However, this is the first reported case of eosinophilic cystitis occurring after intravesical BCG therapy. Manifestations of eosinophilic cystitis are not specific and can mimic those of other inflammatory and malig- From the Department of Urology, Sahloul Hospital, Sousse University, Sahloul, Tunisia Reprint requests: Adnen Hidoussi, M.D., Department of Urology, Sahloul Hospital, Route de ceinture Sousse, Sousse 4054, Tunisia. E-mail address: hidoussi_adnen@ yahoo.fr Submitted December 11, 2006, accepted (with revisions) July 3, 2007 © 2007 Elsevier Inc. 0090-4295/07/$32.00 591.e9 All Rights Reserved doi:10.1016/j.urology.2007.07.032