Invasive Pulmonary Aspergillosis Associated With Marijuana Use In A Man

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In November 2006, a 65-year-old man presented for routine oncology follow-up with a 1-month history of cough, exertional dyspnea, and fever. Two years earlier, he had been diagnosed with colorectal cancer and treated with resection and adjuvant chemotherapy (fluorouracil and folinic acid). Nine months before his current visit, he was diagnosed with metastatic disease in his lungs and pelvis and had completed eight cycles of combination chemotherapy (capecitabine, irinotecan, and bevacizumab every 3 weeks), resulting in a significant reduction in tumor burden. At the clinic visit, his scheduled ninth cycle of chemotherapy was postponed, and he was prescribed a 7-day course of empiric moxifloxacin for presumed bacterial pneumonia. Despite this, he experienced progressive fatigue, increasing dyspnea, and small-volume hemoptysis, and presented to the emergency department. He had no other medical history of note. He was born in Canada and had no known exposure to tuberculosis. He took no regular medications. Although he had never smoked cigarettes, he had started smoking marijuana for the palliation of chemotherapy-induced nausea 6 weeks before presentation. Physical examination, including pulse oximetry and chest auscultation, was normal. The WBC (7.9 × 109/L) and neutrophil (5.2 × 109/L) counts were also normal, and no significant neutropenia had been documented during the course of the patient's chemotherapy. Cultures of blood and sputum for bacteria, mycobacteria, and fungi were negative. A computed tomography scan of the chest revealed a new 4.3-cm cavitary lesion (Fig 1, arrow) in the left lower lobe with surrounding ground-glass opacities. A computed tomography—guided fine-needle aspirate of the cavity was performed; microscopic examination demonstrated necrosis, inflammation, and masses of hyaline fungal hyphae with dichotomous branching and septations, compatible with Aspergillus species (Fig 2A). Fragments of plant matter, likely inhaled cannabis, were also present in the sample (Fig 2B). There were no malignant cells. Although no organisms were detected by conventional microbiologic techniques, polymerase chain reaction—based nucleic acid amplification and sequencing confirmed the presence of Aspergillus fumigatus in the aspirate. A 3-month course of voriconazole, the current standard therapy,1 was administered for a diagnosis of invasive pulmonary aspergillosis. Six months after completing antifungal therapy, the patient has had total symptomatic and radiographic resolution of his infection.

Source: Invasive Pulmonary Aspergillosis Associated With Marijuana Use in a Man With Colorectal Cancer