What’s the connection between lemon juice and disseminated candidiasis in my patient with illicit IV drug use?

Lemon juice is often used by IV drug users to help dissolve poorly water soluble street drugs, such as brown heroin or crack-cocaine, and may serve as a vehicle for Candida albicans infection. 1-3

Contamination of lemon juice (either from wild lemons or from the plastic containers) is thought to occur from either the skin and/or oropharynx of the user.1  Other fruit juices such as orange juice as well as raspberry syrup have been implicated as a source of disseminated candidiasis in IV drug users.4

Experimental inoculation of lemons with small numbers of C. albicans has demonstrated rapid growth of the organism at room temperature resulting in inadvertent injection of a large inoculum size. 2 Once inoculated directly into the blood stream, C. albicans disseminates and can present in many ways, including skin lesions, ocular lesions/endophthalmitis, and osteoarticular infections (eg, costochondral, hip joint, and vertebral infections).1  

So it is advisable to not only ask about what recreational drug is being injected but also what it is injected with!

Bonus Pearl: Did you know that although lemon juice is an excellent growth medium for C. albicans, it has bactericidal properties against Staphylococcus aureus and Pseudomonas aeruginosa? 1

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References

  1. Bisbe J, Miro JM, Latorre X, et al. Disseminated candidiasis in addicts who use brown heroin: report of 83 cases and review. Clin Infect Dis 1992;15:910-23. https://www.ncbi.nlm.nih.gov/pubmed/1457662
  2. Newton-John HGF, Wise K, Looke DFM. Role of the lemon in disseminated candidiasis of heroin abusers. Med j Aust 1984;140:780-81. https://onlinelibrary.wiley.com/doi/abs/10.5694/j.1326-5377.1984.tb132597.x?sid=nlm%3Apubmed
  3. Shankland GS, Richardson MD. Source of infection in candida endophthalmitis in drug addicts. Br J Ophthalmol 1986;292:1106-7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1954783/pdf/702.pdf
  4. Scheidegger C, Pietrzak J, Frei R. Methadone diluted with contaminated orange juice or raspberry syrup as a potential source of disseminated candidiasis in drug abusers. Eur J Clin Microbiol Infect Dis 1993;12:229-31. https://link.springer.com/article/10.1007/BF01967124
What’s the connection between lemon juice and disseminated candidiasis in my patient with illicit IV drug use?

My diabetic patient complains of acute blurred vision past few days since her blood glucoses have been out of control. How does high blood glucose affect the vision acutely?

“Vision loss or blurriness” is one of the most common manifestations of acute hyperglycemia in diabetic patients and is due to the osmotic swelling of the lens resulting in changes in its characteristics and the inability to properly focus an image.1

Since glucose acts as a solute, an increase in the concentration of glucose causes a rise in osmotic forces and movement of fluid into the lens, resulting in transient myopia. Interestingly, the increase in the fluid in the lens causes a change in its refractory index which is associated with focusing an image at a different length; it does not affect  its curvature or position. 

Baseline vision should be eventually restored by correcting glucose levels.2 Also remember that rapid correction of hyperglycemia may make the lens swelling worse, causing increased visual disturbances.3  

Fun fact: Did you know that chronic hyperglycemia is associated with cataract formation due to excess conversion of glucose to sorbitol in the lens? 4

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References

  1. Bron A.J, Sparrow J, Brown N, Harding J, Blakytny, R. The Lens in Diabetes. Eye 1993; 7: 260-75 https://www.nature.com/articles/eye199360.pdf
  2. Huntjens B. O’Donnell C. Refractive error changes in Diabetes Mellitus. Optometry in Practice 2006; 7:103-114. http://openaccess.city.ac.uk/6185/3/Refractive_Error_Changes_in_DM_FINAL.pdf
  3. Sychev YV, Zepeda EM, Lam DL. Bilateral cateract formation via acute spontaneous fracture of the lens following treatment of hyperglycemic hyperosmolar syndrome: Case report. Am J Ophthalmol 2017;7:66-69. https://www.ncbi.nlm.nih.gov/pubmed/29260081
  4. Pollreisz A, Ursula SE. Diabetic Cataract—Pathogenesis, Epidemiology and Treatment. Journal of Ophthalmology 2010; vol. 2010, Article ID 608751. https://www.hindawi.com/journals/joph/2010/608751

 

Contributed by Felicia Hsu, Medical Student, Harvard Medical School

My diabetic patient complains of acute blurred vision past few days since her blood glucoses have been out of control. How does high blood glucose affect the vision acutely?