Case 29-1998

A 57-year-old man was referred to the hospital because of fever and jaundice. The patient had been in good health until four years earlier, when a noninvasive, papillary transitional-cell carcinoma of the bladder, grade 1 on a scale of 1 to 3, was excised. Similar tumors were excised 12 and 18 months later. One year before admission, live bacille Calmette–Guérin (BCG) microorganisms were administered intravesically, with six weekly instillations followed by seven monthly instillations and periodic cystoscopic examinations. There were multiple difficult catheterizations because of total or partial erections and sphincter spasm. The patient recalled having had “fever and chills” after one treatment. Six and a half weeks before admission, the results of a cystoscopic examination were normal, and microscopical examination of a bladderbiopsy specimen showed only chronic cystitis. Five days before admission, the patient received an instillation after a difficult insertion of the catheter, accompanied by gross hematuria. That evening, severe dysuria developed, with fever, shaking chills, and malaise. A urinalysis and urine culture, performed elsewhere, showed normal findings. Trimethoprim– sulfamethoxazole was prescribed empirically. During the next three days, the patient had jaundice, dark urine, light stools, vague abdominal discomfort, anorexia, and fatigue, and his temperature rose to 38.7°C. Laboratory tests were performed (Table 1). On the evening before admission, epistaxis occurred. He was admitted to the hospital the next day. There was a history of hypertension for which the patient took enalapril. He reported no risk factors for human immunodeficiency virus infection. The temperature was 37.8°C, the pulse was 100, and the respirations were 16. The blood pressure was 170/95 mm Hg. On examination, the patient was deeply jaundiced and appeared ill. There was no rash or lymphadenopathy. A grade 1 systolic ejection murmur was heard along the right upper sternal border. The results of an abdominal examination were normal; the liver and spleen were not felt, and no tenderness or mass was palpated. There was no peripheral edema or digital clubbing. The results of a neurologic examination were normal. The urine was orange; it was positive (+++) for bilirubin and positive (trace) for ketones and protein, with a pH of 5.5 and a specific gravity of 1.019. The sediment contained 3 to 5 red cells, 10 to 20 white cells, and a few bacteria per high-power field. The results of laboratory tests are shown in Tables 1 and 2. A radiograph of the chest was normal. An ul*To convert the values for total and conjugated bilirubin to micromoles per liter, multiply by 17.1. T ABLE 1 . B LOOD C HEMICAL V ALUES .