Granulomatous Hepatitis Following Intravesical Bacillus Calmette–Guérin (BCG) Therapy Presenting as Acute-on-Chronic Liver Failure (ACLF): A Case Report

Intravesical Bacillus Calmette–Guérin (BCG) immunotherapy is an established adjuvant treatment for non–muscleinvasive bladder carcinoma. Although generally well tolerated, systemic complications including granulomatous hepatitis are rare and potentially life-threatening. We report the case of a 74-year-old man with carcinoma urinary bladder who developed jaundice, altered sensorium, and acute kidney injury following intravesical BCG therapy. Laboratory evaluation demonstrated severe cholestatic liver injury with bilirubin 26.8 mg/dL and INR 1.9. Viral and autoimmune workup was negative. Upper gastrointestinal endoscopy revealed mild portal hypertensive gastropathy without varices. Liver biopsy demonstrated portal and lobular inflammation with epithelioid granulomas and cholestatic changes favoring BCG-related granulomatous hepatitis. This case shows a rare event, when patient developed Acute-onChronic Liver Failure (Granulomatous hepatitis) following BCG therapy.