Heroin's Deadly Smoke: Unrelenting Fungal Meningitis Attacks Brain

The victim arrived in the Emergency Department with headache, nausea, and fever. When he developed paralysis, doctors summoned neurologist Simona Ferioli, MD, and neurology resident Joao Mc-O’Neil Plancher, MD, from the Neurocritical Care Program of the University of Cincinnati (UC) Neuroscience Institute.

"Although the patient arrived from another institution with a diagnosis of stroke, his symptoms were unusual for stroke,” Plancher says. "Upon learning of his history of drug use, we investigated further and treated him for infectious causes.”

Despite urgent treatment with antibiotics, antiviral and antifungals, the patient died a few days later. What had happened?

Plancher explained the case in a poster presentation titled "Fulminant cerebral zygomycosis in a healthy man: a case of heroin inhalation” at the 67th Annual meeting of the American Academy of Neurology in April in Washington. Poster co-authors were Ferioli and Christopher Kiefer, MD.

Heroin can be injected, snorted, sniffed, swallowed or smoked. Most users typically inject the drug into a vein or muscle. Today’s young new users often prefer to smoke or snort it, in a pipe or mixed with a regular or marijuana cigarette, wrongly believing this is not as addictive. But heroin is highly addictive in any form, according to the National Institute on Drug Abuse. It acts on the opioid receptors found in many areas of the brain and body, especially those involved in pain suppression and reward perception. In cases of overdose, it has often affected the brain stem to suppress breathing.

When the patient’s autopsy report came back to the neurologists, they saw the damage: broad ribbon-like branches of fungus extended throughout the brain tissues. Areas of dying tissue (necrosis) and bleeding (hemorrhage) had caused the fatal brain swelling. The fungus was identified as zygomycosis.

How did fungi typically found in the soil (in decaying leaves, compost, or rotten wood) get into the brain of this heroin user? "The heroin itself or needles used for injection could have been contaminated with spores,” Ferioli says. "Then, the spores either circulated in the blood to the brain or were transported via the smoke. It’s not an uncommon fungus. But it can be devastating if it enters the bloodstream, even in healthy individuals.”

This infection typically develops in a person whose immune system is compromised, such as with chronic disease. It can also happen in IV drug use or heroin inhalation because the nose tissues are filled with blood vessels, which can be already damaged by snorting. A zygomycosis infection can be deadly, with mortality rates reaching as high as 68 percent. However, early diagnosis and treatment can lead to better outcomes.

Besides infection, devastating and fatal brain injuries from drug abuse are on the rise as the heroin epidemic worsens. Respiratory arrest, massive strokes and other toxic effects on the brain occur because of the drug itself or when it mixes with other substances.

Deaths from overdoses are increasing. Thousands of heroin users, part of a Midwest epidemic, are unknowingly risking the deadly ravages of the drug’s attack on the delicate neurovascular tissues of the brain.

One particularly high-risk situation occurs when someone stops using heroin, even for as little as one day, and then resumes with the amount used previously. Because of loss of tolerance, the heroin dose is now deadly.

Theresa Winhusen, PhD, division director of addiction sciences in the Department of Psychiatry and Behavioral Neuroscience at UC, says treatment can be effective and recovery is possible. Clinicians can help patients with an opioid addiction with medication-assisted therapies (MATs), including methadone, buprenorphine and naltrexone. Winhusen explains, "MATs help ease cravings and withdrawal.”

Treatment programs vary. Use the treatment locator on the Substance Abuse and Mental Health Services Administration (SAMHSA) to learn more.