Mediterranean Journal of Hematology and Infectious Diseases
January 14, 2011
By: Yousef Gargani, Paul Bishop and David W. Denning
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Marijuana is the most commonly used illicit substance in the UK and many other western countries, despite it being a class B drug. It is available legally in some localities, including the Netherlands. There is a well known link between marijuana use and schizophrenia. There is currently uncertainty about any causal association between marijuana use and lung cancer as the effects of concomitant tobacco smoking amongst these users confound analyses. A small number of cases of various forms of aspergillosis have been associated with marijuana smoking, but the association appears to be uncommon.1–9

We present 2 cases of chronic pulmonary aspergillosis (CPA) associated with extensive medicinal use of marijuana, and summarise the literature linking all forms of aspergillosis and marijuana use.

Patient 1

A Caucasian male presented at the age of 47 with a right-sided pneumothorax (Figure 1), associated with pulmonary bullae. He had a four year history of progressive breathlessness. His tobacco smoking history was approximately 39 pack*years, but his breathlessness worsened considerably once he started to smoke marijuana (5 marijuana cigarettes (joints) daily) medicinally to alleviate rheumatoid arthritis-associated joint pain. On presentation, he reported coughing up thick sputum and experiencing some unexpected weight loss. His medications included a 5mg daily dose of prednisolone and 1g dose of sulfasalazine twice a day. His family history included one brother who had TB and another who had a pneumothorax.

Image1Figure 1. Patient 1. Bilateral apical bullae, more marked on the right; associated with a right pneumothorax.

His pneumothorax did not resolve despite drainage; thus he underwent a right bullectomy and pleurectomy. One of the excised bullae (Figure 2) contained a pleural based abscess containing an aspergilloma (Figure 3). His CRP at this time was 333mg/l. Postoperatively his lung function failed to improve and a chest x-ray revealed that that his right lung remained abnormal, with cavitary changes. A CT scan showed severe emphysema with many large lung bullae especially in the left apex (Figure 4). His CRP normalised and his alpha 1 antitrypsin levels were normal.

Image3Figure 2. Appearance of the resected lung showing remarkable loss of normal lung architecture, and large airspaces, especially in section B.

fungalballFigure 3. Appearance of the fungal ball found at surgery.

Image4Figure 4. Patient 1 Postoperative CT thorax showing many large lung bullae in left apex with smaller bullae, and a bullectomy suture line in the right. The aspergilloma and surrounding cavity that was found has been excised.

Pathological evidence of an aspergilloma with symptoms of weight loss and raised inflammatory markers is an indication for antifungal therapy. He was started on posaconazole 400mg bd and took it for 4 months. After treatment both his cough and sputum production improved and his Aspergillus fumigatus precipitin serum titre was 1:4. He stopped smoking marijuana. He was observed for recurrence of CPA for the following 4 years and there was no evidence of recurrence (Figure 5).

Image5Figure 5. Patient 1 Chest radiograph 3 years later, showing generalised emphysema but no recurrence of chronic pulmonary aspergillosis

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