Cannabis and Aspergillus: A Medical Case Study Synopsis
I’m going to start this by stating that I am not a doctor, and the reason that I have linked all of the studies that I’m using is so that people can find and read these articles for themselves. Where possible I will use abstracts to guide the analysis, when it’s not I will try my best to de-jargonify the paper’s findings. They are sorted by date, starting with the most recent research first.
June 2020: Cannabis Use and Fungal Infections in a Commercially Insured Population by Kaitlin Benedict, George R. Thompson, and Brendan R. Jackson
The paper authors, who are from the Centers for Disease Control and Prevention and University of California Davis Medical Center used the 2016 IBM MarketScan Research Databases to examine patient interactions for over 27 million 27 million employees, dependents, and retirees throughout the United States. Using International Classification of Disease codes (ICD10), they looked for information at the intersection of a history of cannabis use in addition to other diagnostic information.
According to the paper’s abstract, they found that persons who used cannabis were 3.5 (95% CI 2.6–4.8) times more likely than persons who did not use cannabis to have a fungal infection in 2016.
“Persons who use cannabis were more likely than persons who did not use cannabis to have mold infections (0.03% vs. 0.01%; OR 3.4, 95% CI 2.1–5.3, aOR 4.6, 95% CI 2.9–7.4) and other fungal infections (0.04% vs. 0.02%; OR 2.2, 95% CI 1.4–3.3, aOR 2.9, 95% CI 1.9–4.5)… Among patients with fungal infections, persons who used cannabis were significantly younger than persons who did not use cannabis (median age 41.5 years vs. 56.0 years; p<0.001), more likely to be immunocompromised (43% vs. 21%; p<0.001), more likely to be hospitalized on the fungal infection diagnosis date (40% vs. 13%; p<0.001), and more likely to have tobacco use codes (40% vs. 9%; p<0.001)”
Aspergillus has a specific ICD-10 Code section, B44, and these codes were used in addition to cannabis use codes in the database. It is noted that cannabis use is often ‘greatly’ underreported to physicians by patients. The table of data is here, and it shows that the greatest incidence of fungal infection in cannabis users that were part of the research is for Aspergillus.
November 2015: Chronic necrotizing pulmonary aspergillosis in a patient with diabetes and marijuana use by Tamara Leah Remington , Jeffrey Fuller, Isabelle Chiu
Chest pain and shortness of breath brought a 29 year old with type 1 (juvenile) diabetes to the emergency room. While initially the patient did not think they had any other symptoms, he did recall night sweats, fever, weight loss, and a general feeling of being unwell for around a year. In addition to insulin, the patient was taking a proton pump inhibitor, which inhibits proton pumps from producing too much acid in the stomach (pantoprazole). The patient vaporized cannabis, acquired from the same dealer from the illicit market, daily for diabetic neuropathy for the last 18 months, in addition to occasional oxycodone.
Around 18 months prior to admission was when initial symptoms of neuropathy presented, and he had this experience for around 6 months before being diagnosed with diabetes (around a year prior to admission), and he was also found to have diabetic retinopathy. Two months later (and 10 months before his presentation at the emergency room), he had been diagnosed with community-acquired pneumonia, and have evidence of abnormal growths (infiltrate) in the lower-left lobe of his lungs. No follow up x-rays were taken. Computerized tomography of his abdoment that was performed for unrelated issues did reveal evidence of ongoing issues in the lower left lung (consolidation). Physical examination was relatively normal except for evidence of decreased air entry to the base of his left lung.
A radiograph and computerized tomography of the lungs showed a pneumothorax and air space disease in the lower left lung. A chest tube did not relieve the symptoms. Video-assisted thorascopic surgery showed diffuse pleural adhesions. As the surgery was both diagnostic and therapeutic, decortication (removal of fibrous tissues around the lung) and a wedge resection (removal) of some of the lower left lung tissue was performed.
The tissue samples from the wedge resection grew a Penicillium species, a non-sporulating fungus…and Aspergillus fumigatus. Blood tests were largerly normal, and revealed that the patient’s immunoglobulins (antibodies) were also normal except for a mildly low level of immunoglogulin G4, which can indicate infection in the respiratory system, stroke in the circulatory system, or possible damage to the kidneys in the urinary system.
The pneumothorax resolved after surgery and the patient was given a six month course of voriconazole, an oral medication for serious fungal or yeast infections. His symptoms resolved, and the resolution was confirmed by radiography tests. Cultures from his cannabis grew Penicillium species, Aspergillus versicolor and Aspergillus ochraceus. His vaporizer, however, did not grow any fungal species.
It is believed that the fungal infection began one year earlier, when the patient had been diagnosed with diabetes – the presence of retinopathy and neuropathy might indicate the patient had a prolonged period of hyperglycemia. Diabetes is a mild immunosuppressive disease, which makes it a risk factor for chronic necrotizing pulmonary aspergillosis.
This case study caused two responses from other Canadian doctors.
February 2001: Early invasive pulmonary aspergillosis in a leukemia patient linked to aspergillus contaminated marijuana smoking by M Szyper-Kravitz, R Lang, Y Manor, M Lahav
This paper details the medical case of a 46 year old patient who presented with fever, chills, and a dry cough. He was started on broad-spectrum antibiotics. His x-rays and physical examination came back normal, but his hematological evaluation revealed acute myeloid leukemia, and induction therapy (aimed at reducing the number of plasma cells) was started in addition to antibiotics. His condition began to worsen, with spiking fever, chills so bad they shook his body, rapid breathing, and low levels of oxygen in the blood (hypoxemia). Blood and sputum samples came back negative for bacteria and fungi. A chest CT indicated abnormal growths (focal nodular infiltrates) in the lung.
An investigation of the patient’s circumstances revealed that the patient smoked daily from a hookah mixing tobacco and cannabis. While waiting for the results of legionella and fungi tests performed on cultures from the hookah water and tobacco, physicians started the patient on antifungal therapy with amphotericin B. The fever and hypoxemia resolved after 72 hours on the medication. The cultures taken from the tobacco came back positive for heavy growth of ‘Apsergillus species’ (the exact species was unspecified).
The authors state: “We suggest that habitual smoking of Aspergillus-infested tobacco and marijuana caused airway colonization with Aspergillus. Leukemia rendered the patient immunocompromised. . . Physicians should be aware of this potentially lethal complication of “hookah” and marijuana smoking in immunocompromised hosts.”
May 2008 Invasive pulmonary aspergillosis associated with marijuana use in a man with colorectal cancer by David W Cescon , Andrea V Page, Susan Richardson, Malcolm J Moore, Scott Boerner, Wayne L Gold
January 2001, with Update in May, 2007: Fungal contamination of tobacco and marijuana (UpdateD)by P E Verweij, J J Kerremans, A Voss, J F Meis
This letter establishes that “Invasive aspergillosis remains a significant cause of morbidity and mortality in immunocompromised patients, including transplant recipients and those treated for hematological malignancy…However, the risk of invasive aspergillosis associated with tobacco or marijuana smoking is unclear.” The authors, all microbiologists from the Netherlands, examined 98 cigarettes from 14 brands and 7 samples of cannabis.
They created an apparatus to ‘smoke,’ and then measured the amount of four species of aspergillus, whether or not the culture was positive for mold, and penicillium. The results of their tests are below.
April 1986: Possible risk of invasive pulmonary aspergillosis with marijuana use during chemotherapy for small cell lung cancer by Sharon Sutton, Bert L. Lum, and Frank M. Torti
A 60 year old with a history of limited stage small cell lung cancer presented at the hospital with skin lesions, 80 pound weight loss, and ‘progressive debilitation.’ 15 months prior to the hospitalization the patient had been diagnosed with a node on his lung, but before that he had enjoyed good health. The small cell lung cancer, limited to the upper lobe of the right lung and a regional lymph node, was treated by removal of the mass, chemotherapy, and prophylactic cranial radiation. The patient’s side effects of nausea, vomiting, and weight loss were not controlled by standard pharmaceutical protocols, so after six cycles of chemotherapy the patient began smoking three to four ‘marijuana cigarettes’ a day to find relief through the rest of his treatments.
Two months before presenting to the hospital, his treatment was considered complete, which was after 12 cycles of chemotherapy. Ten days before he was admitted, fluid filled sacs (cutaneous vesicles) started to appear, thought to be herpes zoster. Two days before he arrived at the hospital cutaneous lesions appeared on his torso and extremities. Routine labs and physical examination came back normal but a chest x-ray showed possibilities of infection processes, such as inconsistent densities of the lung lining and nodes.
After 8 days in the hospital, the patient’s condition deteriorated, and he began to have a fever in addition to more abnormal growths within the lung. Tests of his sputum indicated Klebsiella pneumonia, Streptococcus pneumonia, and Candida, and the patient was started on antimicrobial and systemic antifungal therapy. On day 18 in the hospital, the patient died.
Post mortem examination had no evidence of carcinomas in the lung, but instead revealed necrotizing aspergillus pnemonia.
May 1975: Pulmonary Aspergillosis, Inhalation of Contaminated Marijuana Smoke, Chronic Granulomatous Disease by M J Chusid, J A Gelfand, C Nutter, A S Fauci
In this letter published to Annals of Internal Medicine the four authors recount the case of a 17 year old boy with a genetic disease, chronic granulomatous disease (CGD). CGD causes white blood cells to be unable to kill certain bacteria and fungi. Increased susceptibility to infection is expected with such a disease.
Two weeks before hospital admission, the patient noted some ‘malaise’ that set in 12 hours after “smoking several pipefulls of marijuana that had been buried in the earth for ‘aging.’” A few days later, he developed a cough, and night sweats. When he was physically examined at the hospital, it was unremarkable except for an elevated breath rate of 32 respirations per minute (12 – 18 is normal for an adult). His temperature was slightly elevated at 101 degrees, A chest x-ray did show abnormality, and his blood results showed some signs possible signs of infection / disease (Leukocyte count was 8500/mm3 with 65 % segmented neutrophils, 8% bands, and 5 % eosinophils. Erythrocyte sedimentation rate was 50 mm / min).
Repeated sputum and blood tests came back negative for bacterial and fungal pathogens, and was also negative for tuberculosis. This lead to an open thoracotomy, and the biopsy tested positive for Aspergillus fumigatus.
The patient received intravenous amphotericin B and prednisolone every 8 hours for the next 5 days, and his partial pressure of oxygen values, which measure the effectiveness of the lungs in transporting oxygen to the blood, improved from a low of 38 returned to a nominal range (normally 75-100 in healthy patients).
Cultures later taken from the cannabis and the pipe the patient used came back positive for various fungi, with heavy growth of Aspergillus fumigatus. The authors followed up by testing 10 samples of marijuana from the DEA, and cultures from 2 of the samples grew Asperigllus fumigatus. The author’s conclusions were ” The present case shows that marijuana may at times be
contaminated with Aspergillus fumigatus, and is thus a potential hazard to individuals predisposed to Aspergillus infection. For normal individuals such exposure is probably of little practical significance.”
Pulmonary consequences of marijuana smoking
A 56-year-old woman with COPD and multiple pulmonary nodules
TOO MANY MOULDY JOINTS – MARIJUANA AND CHRONIC PULMONARY ASPERGILLOSIS
Aspergillosis and marijuana. Annals of Internal Medicine.
Chronic necrotising pulmonary Aspergillosis in a marijuana addict: a new cause of amyloidosis.
Up in smoke: An unusual case of diffuse alveolar hemorrhage from marijuana
Allergic bronchopulmonary aspergillosis associated with smoking moldy marihuana
Aspergillus: an inhalable contaminant of marihuana
Pulmonary aspergillosis, inhalation of contaminated marijuana smoke, chronic granulomatous disease.
Aspergillus nodules; another presentation of Chronic Pulmonary Aspergillosis
Aspergillosis Presenting as Multiple Pulmonary Nodules in an Immunocompetent Cannabis User
Disseminated aspergillosis in an HIV-positive cannabis user taking steroid treatment
Cigarette smoke, bacteria, mold, microbial toxins, and chronic lung inflammation
Cannabis contaminants: sources, distribution, human toxicity and pharmacologic effects
Aspergillus: An Inhalable Contaminant of Marihuana
Marijuana smoking and fungal sensitization
Chronic necrotising pulmonary aspergillosis in a marijuana addict: a new cause of amyloidosis
Pulmonary aspergillosis in the acquired immunodeficiency syndrome