Disseminated Candidiasis in Addicts Who Use Brown Heroin: Report of 83 Cases and Review

Abstract

From November 1983 to April 1990, disseminated candidiasis was diagnosed in 83 heroin addicts at our institution. All patients had consumed brown heroin diluted in fresh lemon juice. Sixty-two (75%) had skin lesions, 41 (49%) had ocular lesions, and 35 (42%) had one or several costochondral tumors. Candida albicans was grown in culture or histopathologically identified in 34 cases (41%). The patients who had only cutaneous lesions were treated with ketoconazole, and they were all cured. The patients with ocular involvement received systemic amphotericin B with or without oral flucytosine; 29 of these patients developed varying degrees of vision loss. The method of treatment of costochondral tumors was not uniform; in 14 cases the lesions were resected. The one patient who died developed endocarditis involving the aortic valve. Cases of pleuropulmonary involvement, spondylitis, and large-joint arthritis have also been described among the 300 cases reported in the reviewed literature. This is a new syndrome of candidal infection in drug addicts who use brown heroin; ocular lesions are the most harmful manifestation, and loss of vision is the major sequela.

2015 ESC Guidelines for the management of infective endocarditis

“…Jeśli osoba uzależniona stosuje brązową heroinę rozpuszczaną w soku cytrynowym trzeba dołączyć lek przeciwgrzybiczy, przypuszczając, że czynnikiem etiologicznym mogą być Candida spp. (nie Candida albicans) [435]. Po wyizolowaniu mikroorganizmu odpowiedzialnego za zakażenie należy włączyć leczenie celowane.…”

Gluconobacter as Well as Asaia Species, Newly Emerging Opportunistic Human Pathogens among Acetic Acid Bacteria

“…AAB were also implied or suspected to be responsible for other types of infections, including, in particular, bacteremia in patients for whom the probable source of infection was an indwelling device (1,12,17,27). The known use of acidic substances such as vinegar or lemon juice to dilute heroin (2,28) and the potential contamination of batches of compounds for intravenous drug abuse by AAB (32,33) make us speculate that patient 1 was contaminated after intravenous drug injection, probably during his hospitalization, as he was apyretic at the time of admission. An improvement of the clinical condition of this immunocompetent patient was observed with ceftriaxone treatment, even though this molecule was not active in vitro, without removing the central venous catheter placed for antifungal drug administration.…”

Heroin with a Twist: Candida Glabrata Endocarditis Concurrent with Brain Mycetomas in an IV Drug User

“…Research demonstrated that lemon juice can support C. albicans growth at room temperature [19] and was associated with disseminated candidiasis or Candida endophthalmitis in IVDUs, since lemon juice was used for preparation of brown heroin for intravenous use [4,[20][21][22].…”

“…Risk factors include the presence of prosthetic valves, short term indwelling catheters, broad spectrum antibiotic use, history of health associated care and intravenous drug use [1,2]. A distinct clinical syndrome of disseminated candidiasis in heroin abusers exists [3] and it is associated with the use of lemon in the preparation of heroin prior to injection [4]. Manifestations include development of lesions in the skin of hair bearing areas such as the scalp, the beard, and the axillary and pubic areas where pustules are formed in the location of follicles, ocular lesions such as episcleritis and chorioretinitis, and lesions in bone and costal cartilage [3].…”