Fatal Aspergillosis Associated with Smoking Contaminated Marijuana, in A Marrow Transplant Recipient: Discussion

11 Feb

Aspergillus spores are ubiquitous and are the most frequently found fungus in the environment. Increased concentrations of spores have been noted in winter months. Pathogenicity of the Aspergillus species has to do with properties of the spores; namely their light weight, thick walls and small size which allow for their growth in terminal bronchioles. Host predisposing factors are most often related to the presence of underlying pulmonary disease such as asthma, possibly cystic fibrosis, old tuberculous cavitary disease, and/or to alterations in immune function such as in chronic granulomatous disease or neoplasia. In acute leukemia, invasive pulmonary aspergillosis classically occurs in the setting of prolonged granulocytopenia and often presents with unremitting fever and development of pulmonary infiltrates in the face of antibiotic therapy. contraceptive pills

Diagnosis of aspergillosis is often difficult to establish without lung biopsy. Blood culture and Aspergillus precip-itins are not helpful. Sputum culture is positive in about 30 percent of patients, but may be useful in the diagnosis of invasive disease in selected patient subgroups. Nasal cultures have been reported to help identify patients at risk for aspergillosis. Recently, detection of Aspergillus antigen has been described and seems to offer some advantage over the methods mentioned above. Our patients presentation was atypical in that he developed invasive aspergillosis two months after BMT and weeks after recovery of his neutrophil count.
We evaluated the possible role that marijuana had served as a source of exposure to Aspergillus organisms. A sample of the patients marijuana grew two morphotypes of Aspergillus fumigatus, one blue-green and one white colony type. Final identification was based on microscopic characteristics of vegetative growth. Both produced thin-walled, smooth conidiophores with flask-shaped vesicles. Conidia were columnar and phialides were uniseriated. Each colonial morphotype was isolated and each could be converted on subculture to both the white and blue-green colony types. Both morphotypes grew at 45°C. The same identification procedures were used to speciate the Aspergillus from the patients lung biopsy specimen. The presence of both white and blue-green colony types of Aspergillus fumigatus in both the patients and marijuana specimens suggests that the same strain of Aspergillus fumigatus was present in the marijuana and in the lung biopsy from the patient.
Exposure to marijuana has been implicated in other diseases. In 1981, marijuana was identified as the cause of a multistate outbreak of salmonellosis. Some observers noted the association of respiratory tract fungal infection with the use of contaminated marijuana. Kagen demonstrated the presence of Aspergillus in 11 of 12 marijuana samples and showed that the spores passed easily through contaminated cigarettes and most marijuana smokers had precipitins against Aspergillus.
The present case shows that smoking marijuana may subject immunosuppressed patients to the potential of serious opportunistic fungal infection. Physicians caring for such patients should be aware of this potentially lethal complication, especially since patients may smoke marijuana to relieve nausea from chemotherapy.