Tuesday, 23 June 2015

Disseminated Candida infection syndrome in heroin addicts

Disseminated Candida infection syndrome in heroin

addicts-dominance of a single Candida albicans



Department of Microbiology, University of L eicester, L eicester L E 7 7RH, *Hospital 7 de Octubre, Madrid,
Spain, and t Departmento de Dermatologia, Hospital General Valhncia, Spain

Summary. Among 21 intravenous heroin abusers with cutaneous and ocular

manifestations of disseminated Candida infection, a single C. albicans strain type

(serotype A, biotype 153/7) was isolated from skin lesions in 14 cases. This suggests

that central contamination of the heroin with C. albicans is less likely to be the source

of infection than an endogenous source, and that one particular strain type is either

better adapted than others to grow in the lemon juice used as a heroin solvent, or

more likely than others to cause the specific pathology seen in these patients.


There is now an extensive literature on a specific

syndrome of disseminated Candida infections in

heroin addicts. The infections are characterised by

several features, of which chorioretinitis and follicular

and nodular skin lesions are the most common,

and associated in some instances with costochondral

arthritis (Barthelemy et al., 1981 ; Dally et al.,

1982; Mellinger et al., 1982; Badillet et al., 1983;

Collignon and Sorrell, 1983; Dally et al., 1983;

Drouhet and Dupont, 1983; Hoy and Speed, 1983;

Mackay, 1983; Tkpies Barba et al., 1983; Cuadra

et al., 1984; Dupont and Drouhet, 1985; Servant et

al., 1985). C. albicans has been isolated almost

invariably from the cutaneous lesions, but rarely

cultured from the blood or vitreous fluid. The

sources of the fungus in these cases remain

uncertain. Although some authors have suggested

that C. albicans may contaminate brown (street)

heroin (Mellinger et al., 1982; Dally et al., 1983),

attempts to culture C. albicans from the heroin

involved have been unsuccessful (Mellinger et al.,

1982; Dally et al., 1983; Dupont and Drouhet,

1985 ; Servant et al., 1985 ; Shankland et al., 1986),

and there is evidence that heroin inhibits the growth

of C. albicans in vitro (Dupont and Drouhet, 1985;

Servant et al., 1985; Shankland et al., 1986). The

lemon juice used by addicts as a heroin solvent has

frequently been postulated as a source (Hoy and

Speed, 1983; Mackay, 1983; Newton-John et al.,

1984; Servant et al., 1985; Shankland et al., 1986),

and Shankland et al. (1986) recovered C. albicans

Received 8 Jul. 1986; revised version accepted 1 Aug. 1986.

from the juice in two plastic lemons submitted by

addicts. Other postulated sources are use of unhygienic

injection techniques (Barthelemy et al., 198 1 ;

Badillet et al., 1983) and the direct spread of C.

albicans from the gut (Dupont and Drouhet, 1985).

So far, no attempt appears to have been made to

establish which biotype or biotypes of C. albicans

have been involved in the heroin-associated infections,

yet if a single biotype was responsible for all

the cases it would be strong evidence in support of

a single central source of infection. We have

therefore undertaken a survey of C. albicans

biotypes from cutaneous lesions in 21 Spanish

patients with heroin-associated Candida infections.

Patients and methods

The study group comprised 18 male and three female

heroin abusers, aged 19-33, who had presented at clinics

in Madrid or Valencia within the last 2 years. The

patients had high fever (not noted in one case only) that

within 2-7 days was followed by the development of skin

changes. All the patients hadnodular or follicular lesions,

or both, affecting the scalp. Males frequently had a

folliculitis of the beard area. In four cases there were

nodular lesions in the pubic area, and one patient had

follicular lesions on the neck, chest and arms. There were

signs of Candida endophthalmitis in 7 of the 21 patients.

Blood cultures for bacteria and fungi gave negative

results in all 21 cases; however, all the patients yielded

high numbers of C. aZbicans in cultures from the skin



276 F. C. ODDS ET AL.

C. albicans biotyping
The C. albicans isolates were biotyped according to the

methods of Odds and Abbott (1980,1983). The biotyping

tests were repeated on three occasions to ensure consistency

of results. From 16 of the patients a single isolate

was tested; from the other five, isolates from at least two

anatomical sites were tested.

A control group of 45 C. albicans isolates was obtained

from the same Madrid clinic that was attended by 12 of

the patients with the heroin-associated Candida infection.

Clearly, these control isolates could not be obtained from

lesions similar to those of the heroin addicts; 43 were

from patients with Candida vulvovaginitis, one each from

skin and nail lesions.


Fourteen (67%) of the 21 patients with heroinassociated

disease were infected with C. albicans

biotype 153/7.T he other seven were types 075, 135,

137, 175, 253, 557 and one indeterminate type. All

the isolates were serotype A and all could use citrate

as a carbon source. In the three cases where isolates

were obtained from different anatomical sites, all

the isolates were type 153/7. The prevalence of

biotype 153/7, serotype A strains in the control

isolates was 11.1% (5 out of 45). Thirteen (28.9%)

of the control isolates were serotype B; these did

not include any examples of biotype 1 53/7.


These results indicate a greatly heightened

prevalence of C. albicans biotype 15 /7 in patients

with heroin-associated Candida infection that may

be accounted for in two ways. First, the source of

the fungus could be the heroin itself or its acid

solvent; second, type 153/7, serotype A, whatever

its source, may have a higher predilection for

causing infection than other biotypes of C. albicans.

If the heroin were the source, it is difficult to

understand why some of the isolates were not

biotype 153/7. The idea of contamination of the

lemon juice solvent, either for individuals injecting

their heroin alone or for small groups sharing lemon


Badillet G, Pietrini P, Puissant A 1983 Pustuloses chez des

hirohomanes. Annales de Dermatologie et Venereologie 110 :


Barthelemy F, Offret H, Saragoussi J J, Pouliquen Y, Dhermy P
1981 Toxicomanies et endophthalmies Candida albicans :

probltimes diagnostiques et thirapeutiques. Journal Francais

dOphthalmologie 4: 637-646.

Burnie J P, Odds F C, Lee W, Webster C, Williams J D 1985
juice, is entirely compatible with our results and

with the observations that C. albicans grows well in

fresh lemon juice (Newton-John et al., 1984) and

can sometimes be recovered from lemon juice used

by addicts (Shankland et al., 1986). It is notable

that all the isolates from the addicts gave positive

results in the citrate biotyping test, indicating their

ability to grow on citrate at a low pH value (Odds

and Abbott, 1980).

C. albicans type 153/7 is closely related to a type

(0/155/7p)r eviously found to be responsible for an

outbreak of systemic Candida infection in a hospital

intensive care unit and to possess an enhanced

ability to adhere to epithelial cells (Burnie et al.,

1985). Its isolation in the majority of cases of the

Candida-heroin addiction syndrome is, therefore,

compatible with the possibility of endogenous

infection of the addicts. C. albicans is a ubiquitous

member of the normal human microflora, and it is

evident from the control isolates in this study that

type 153/7 is a common biotype amongst vaginal

isolates. A previous survey showed that the frequencies

of different C. albicans biotypes are similar

regardless of their anatomical site of isolation, and

that types 153 and 157 belong to the most numerous

group of C. albicans biotypes (Odds et al., 1983).

The 1 1 % prevalence of type 1 53/7 in vaginal isolates

is, therefore, likely to indicate the normal prevalence

of this type in other sites, including the gutnormally

held to be the major human reservoir of

C. albicans.

In the absence of prospectively gathered data

concerning Candida colonisation of heroin addicts

with and without the systemic Candida infection

syndrome we conclude that candidaemia may be a

common sequel to intravenous heroin usage, either

directly or indirectly (via lemon juice) from a

reservoir, presumably endogenous to the user(s)

and that C. albicans serotype A, biotype 153/7 is

more likely to be involved in invasive disease in

addicts than are other strain types of the fungus.

We thank Miss B. K. Gill for technical assistance. This work

was supported by a grant from the Wellcome Trust.

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