Low-grade fever (<38.5°C) in the absence of hemodynamic instability is a benign immune response to mycobacterial exposure in most cases. Outpatient symptomatic treatment with oral antipyretics is typically all that is necessary. Resolution should be expected within 24-48 h of treatment (Rischmann et al. 2000). Highgrade fever (>39.5°C), which develops in 3%-4% of patients, or persistent low-grade fever are more worrisome (Lamm et al. 1992; Resel Folkersma et al. 1999). Current recommendations are to evaluate all patients with fevers above 38.5°C or 39.5°C lasting longer than 24 or 12 h, respectively, and to initiate single-agent antitubercular treatment on an empiric basis (Malkowicz 2002). The evaluation of BCG-related fever includes a CBC as well as serum electrolytes, creatinine, liver function studies, and mycobacterial blood cultures. Gram-negative sepsis is not an uncommon cause of fever in this patient population; therefore standard blood and urine cultures should also be obtained in order to rule out infection by common urinary pathogens. Respiratory symptoms suspicious for pulmonary infection warrant a plain radiograph of the chest. Isoniazid (INH) (300 mg once a day by mouth) is the antitubercular agent of choice for BCG-related fever. The most common adverse effect of INH is transient hepatitis manifest as elevated serum transaminase levels. This occurs in 10%-20% of patients and should normalize despite the continuation of treatment (Lamm et al. 1992). Isoniazid is continued for 3 months and need only be discontinued if transaminases rise above three times the upper limit of normal. Prophylactic INH has not been shown to reduce the incidence of fever or systemic infection (Durek et al. 2000). Moreover, prophylactic INH diminishes the immune response and impairs antitumor activity (de Boer et al. 1992).
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