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

10 Feb

Fatal Aspergillosis Associated with Smoking Contaminated Marijuana, in A Marrow Transplant RecipientInvasive aspergillosis has become a significant cause of death in immunosuppressed patients. Patients with acute leukemia and lymphoma are particularly susceptible. Postulated risk factors include granulocytopenia, and treatment with corticosteroids, antibiotics and cytotoxic chemotherapy. Qualitative disorders of granulocyte function described in acute leukemia may also increase the risk of Aspergillus infection. Because Aspergillus species are found in soil, air, and vegetable matter (including tobacco), inadvertent exposure is likely. We report a case of disseminated Aspergillus fumigatus infection in a bone marrow transplant recipient associated with the use of contaminated marijuana. acular eye drops

Case Report
A 34-year-old man with Philadelphia chromosome-positive chronic myelogenous leukemia was admitted to the hospital for an allogeneic bone marrow transplant (BMT) following chemotherapy and splenectomy. He was pretreated with cyclophosphamide, total body irradiation and intrathecal methotrexate and maintained on cyclosporin and corticosteroid prophylactic therapy. His course was complicated by acute graft-vs-host disease (GVHD) that resolved on high-dose steroid therapy. He was discharged in good condition on the 39th day after BMT. His drug regimen included cyclosporin, prednisone (30 mg twice daily), ketoconazole (200 mg daily), and gamma globulin (32 g intravenously every two weeks).
The patient remained transfusion-independent and clinically well until day 75 post-BMT when he had two generalized tonic-clonic seizures. Lumbar puncture yielded normal CSE Brain CT scan was unremarkable. Magnetic resonance imaging of the brain showed two parietal nodules. Chest roentgenogram revealed multiple nodules, several of which were cavitary Bronchoalveolar lavage was not diagnostic by Gram-stain, KOH wet mount or bacterial culture. The patient was empirically started on intravenous amphotericin-B therapy Open lung biopsy was performed, which revealed septate hyphae in the direct KOH wet mount of the tissue.
Fungal cultures of the lung tissue and bronchial lavage fluid subsequently grew Aspergillus fumigatus; viral cultures yielded cytomegalovirus. Further history revealed that the patient had been smoking marijuana daily for several weeks prior to admission. Culture of his marijuana yielded Aspergillus fumigatus. Pathologic examination of the submitted lung tissue revealed both fungal and cytomegaloviral pneumonitis.
Despite aggressive therapy with amphotericin B and the experimental drug DHPG (9-[l,3 dihydroxy-2 propoxymethyl] guanine), the patient developed a progressive interstitial pneumonia that required intubation and ventilatory support. He continued to deteriorate with worsening of his pulmonary status, development of cholestatic jaundice and renal insufficiency. The addition of high-dose steroid treatment did not improve his condition. He expired 110 days after bone marrow transplantation. Autopsy revealed disseminated aspergillosis involving the lung, endocardium and brain, together with cytomegaloviral pneumonitis.