Dermatological Manifestations of Disseminated Bacillus Calmette-Guerin Infection in the Intensive Care Unit

We report a case of disseminated Bacillus Calmette-Guerin (BCG)-itis with zosteriform skin eruption, purpura, and livedo racemosa in a 70-year-old critically ill patient who has a history of in situ bladder carcinoma treated with intravesical BCG instillations for the last three years. He presented with fever, fatigue, and a painful lesion on his back, initially diagnosed as herpes zoster. Despite antiviral treatment, he exhibited persistent fever, an inflammatory syndrome, and mild liver enzyme elevation. Initial imaging revealed findings consistent with pneumonia, for which antibiotics were prescribed with no improvement. A subsequent fluorodeoxyglucose (FDG) PET scan identified hypermetabolic lesions in the liver, prompting a biopsy that showed non-caseating granulomas. Skin biopsies from the zosteriform papular eruption on the back and purpura with livedo racemosa on the right foot revealed non-caseating granulomas. Specific Wade Fite staining performed on skin biopsies indicated evidence of mycobacterial infection. Additionally, cultures and Ziehl-Nielsen staining of blood and bone marrow confirmed Mycobacterium bovis infection, establishing the diagnosis of disseminated BCG-itis. Treatment with rifampicin, ethambutol, and moxifloxacin, and a later switch to isoniazid, along with corticosteroids, resolved the skin lesions and improved the patient's condition. This case underscores the diagnostic challenges and the importance of considering disseminated BCG-itis in patients treated with prior intravesical BCG instillations for in situ bladder carcinoma presenting with persistent fever, multi-organ involvement, and diverse skin manifestations including zosteriform papules, purpura, and livedo racemosa.