Br J Ophthalmol. 2007 May; 91(5): 702–703.
PMCID: PMC1954783
Lemon juice and Candida endophthalmitis in crack‐cocaine misuse
The
Centers for Disease Control and Prevention recently reported that a
substantial number of drug misusers in the US are injecting
crack‐cocaine instead of smoking it,1
owing to the decreased availability and increased cost of powdered
cocaine. The use of lemon juice to dissolve crack‐cocaine has been shown
to cause abscesses, permanent vein damage and infections.2 Furthermore, heroin dissolved in preserved lemon juice was documented to be a source of Candidaalbicans in multiple, small epidemics of fungal endophthalmitis in the 1980s in the UK and Australia.3,4
We report here two recent cases of fungal endophthalmitis in crack
users who similarly disclose dissolving crack‐cocaine in lemon juice
injection.
Case 1
A
34‐year‐old male intravenous drug user presented to his primary care
physician with high fever and bilateral blurry vision for the past
20 days. Blood cultures and ECG were negative. The patient reported
dissolving crack in preserved lemon juice.
His
visual acuity was 20/40 OD and 20/70 OS. Dilated fundus examination
revealed multiple condensations in the vitreous with choroidal and
retinal foci in both eyes. A pars plana vitrectomy was performed OD with
intravitreal injections of vancomycin (1 mg/0.1 ml), ceftazidime
(2 mg/0.1 ml) and amphotericin B (7.5 μg/0.1 ml). Vitreous cultures grew
Candida albicans, and the patient was treated with oral
diflucan (200 mg daily). The patient received five intravitreal
injections of amphotericin B (5 μg/0.1 ml) in the vitrectomised right
eye and three in the non‐vitrectomised left eye over 3 weeks for
persistent active lesions. At the most recent examination, 12 weeks
after presentation, the patient's vision was 20/20 OD and 20/50 OS.
Case 2
A
37‐year‐old homeless male intravenous drug user reported a 3‐month
history of decreased vision, eye pain and floaters in his right eye. His
medical history was significant for HIV (recent CD4 count of 799
cells/mm3) and hepatitis C. The patient reported the use of preserved lemon juice to dissolve crack‐cocaine for injection.
His
visual acuity was hand motions OD and 20/20 OS. Dilated fundus
examination of the right eye was obscured by 3+ vitritis, but there
appeared to be a large infiltrate in the macula. A vitreous aspiration
was performed, with intravitreal injections of ceftazidime (2 mg/0.1 ml)
and vancomycin (1 mg/0.1 ml) in the right eye. The vitreous aspire grew
C albicans. Amphotericin B (5 mg/0.1 ml) was injected, and the
patient was admitted for intervenous flucanozole (400 mg four times a
day). Blood cultures and ECG were negative. A therapeutic vitrectomy
with a lensectomy was performed. Ten days postoperatively, the patient's
vision improved to 20/400 OD, with a decrease in inflammation and
resolution of the infiltrate, whereas the left eye was unchanged. The
patient was unfortunately lost to follow‐up.
Comment
Potential
sources of infection in injecting drug users are the impure drug
itself, poorly disinfected skin at the site of injection, unsterile
preparation of the drug, and/or contaminated needles or syringes. This
report raises the possibility that the lemon juice used to dissolve
crack‐cocaine might be another risk factor for fungal infection. In
treating injecting drug users, ophthalmologists should inquire about the
use of preserved juices. If used, this should raise the concern of
fungal endophthalmitis. Furthermore, when an injecting drug user is
infected with fungal endophthalmitis, it might be recommended to advise
other users, who share the lemon juice, of the risk for endophthalmitis.
Finally, public health efforts to decrease the morbidity of intervenous
crack‐cocaine use should discourage users from dissolving crack‐cocaine
in lemon juice. In fact, outreach programmes in certain inner cities
are distributing packets of ascorbic acid to injecting drug users.
Footnotes
Funding:
Unrestricted grant from Research to Prevent Blindness, New York,
NewYork, USA RNK is a Heed Fellow and supported by the Heed Ophthalmic
Foundation
Competing interests: None.
Informed consent was obtained for publication of the persons details in this report.
References
1. Santibanez S S, Garfein R S, Swartzendruber A. et al
Prevalence and correlates of crack‐cocaine injection among young
injection drug users in the United States, 1997‐1999. Drug Alcohol
Depend 2005. 77227–233.233. [PubMed]
2. Buchanan D , Tooze JA , Shaw S , et al
Demographic, HIV risk behavior, and health status characteristics of
“crack” cocaine injectors compared to other injection drug users in
three New England cities. Drug Alcohol Depend 2006. 81221–229.229. [PubMed]
3. Servant J B, Dutton G N, Ong‐Tone L. et al Candidal endophthalmitis in Glaswegian heroin addicts: report of an epidemic. Trans Ophthalmol Soc UK 1985. 104(Pt 3)297–308.308. [PubMed]
4. Newton‐John H F, Wise K, Looke D F. Role of the lemon in disseminated candidiasis of heroin abusers. Med J Aust 1984. 140780–781.781. [PubMed]
Articles from The British Journal of Ophthalmology are provided here
No comments:
Post a Comment