Mycobacterium bovis Infection of Total Knee Arthroplasty After Bacillus Calmette-Guérin Therapy for Bladder Cancer
We present a case of Mycobacterium bovis infection of a total knee arthroplasty. This infection developed after use of bacillus Calmette-Guérin immunotherapy used to treat superficial bladder cancer. The patient presented with joint stiffness. Radiographs and inflammatory markers were normal. Six weeks after arthroscopy for synovectomy and biopsy, cultures showed M bovis infection of the knee joint. The patient was switched to antitubercular chemotherapy treatment, which resulted in the successful retention of implants. Seven and a half years later, the patient is symptom-free with high function in the joint. To our knowledge, this is the first time that this type of joint infection did not lead to removal.
Conclusion
Joint replacement patients with bladder cancer represent a relatively small cohort. Based on current demographics and the increasing demand for joint arthroplasty, it is likely that this unique subset of patients will grow. No current standard of care exists for the treatment of these patients. One preventative measure is to consider alternative types of chemotherapy for bladder cancer treatment, such as mitomycin. Another potential solution would be administration of prophylactic doses of antitubercular agents concomitantly with intravesicular BCG, which would allow for the local effects of BCG immunotherapy while controlling the potential for systemic dissemination. The optimal dose range to achieve this dual effect is not known and is an area for research.
It is important for both arthroplasty surgeons and urologists to be aware of this potential complication in order to appropriately counsel this unique subset of patients. Our case report is the first to demonstrate that a successful outcome can be obtained with retention of primary components. Through research and continued data acquisition, a more concrete standard of care can be established. Until then, we recommend a collaborative approach between informed parties to devise a patient-specific plan of care.
