Israel Medical Association Journal

We present a case of a 65-year-old woman diagnosed with papillary urothelial carcinoma and treated with intravesical bacillus Calmette-Guérin (BCG) instillations. The patient developed systemic BCG infection involving the liver and bone marrow (often referred to as BCGitis), complicated by hemophagocytic lymphohistiocytosis (HLH). Although BCGitis is a known adverse event, progression to HLH is rare, particularly in immunocompetent adults. Despite early recognition and escalation of therapy, including intravenous immunoglobulin (IVIG), corticosteroids, and an IL-1 antagonist, the prognosis remained poor, which was consistent with prior reports of high mortality in tuberculosis-associated HLH syndrome (TB-HLH). The diagnosis was microbiologically supported by GeneXpert Ultra, despite negative Ziehl-Neelsen staining and culture, underscoring the importance of molecular diagnostics in suspected BCG-related complications.

Metastatic pulmonary calcinosis (MPC) is characterized by deposits of calcium in normal pulmonary parenchyma. Diffuse pulmonary calcinosis commonly occurs in hypercalcemia and/or hyperphosphatemia and is more commonly related to renal failure than primary hyperparathyroidism, skeletal metastases, or multiple myeloma [1]. Calcium depositions favor alkaline tissue and are thus more common in the upper lobes of the lung, which have a higher ventilation to perfusion ratio and a low capillary pCO₂, resulting in an alkaline pH [2]. Therefore, the most common radiographic manifestation consists of poorly defined nodular opacities bilaterally in the upper lung zones [3].