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Br J Ophthalmol. 2007 May; 91(5): 702–703.
PMCID: PMC1954783

Lemon juice and Candida endophthalmitis in crack‐cocaine misuse

The Centers for Disease Control and Prevention recently reported that a substantial number of drug misusers in the US are injecting crack‐cocaine instead of smoking it,1 owing to the decreased availability and increased cost of powdered cocaine. The use of lemon juice to dissolve crack‐cocaine has been shown to cause abscesses, permanent vein damage and infections.2 Furthermore, heroin dissolved in preserved lemon juice was documented to be a source of Candidaalbicans in multiple, small epidemics of fungal endophthalmitis in the 1980s in the UK and Australia.3,4 We report here two recent cases of fungal endophthalmitis in crack users who similarly disclose dissolving crack‐cocaine in lemon juice injection.

Case 1

A 34‐year‐old male intravenous drug user presented to his primary care physician with high fever and bilateral blurry vision for the past 20 days. Blood cultures and ECG were negative. The patient reported dissolving crack in preserved lemon juice.

His visual acuity was 20/40 OD and 20/70 OS. Dilated fundus examination revealed multiple condensations in the vitreous with choroidal and retinal foci in both eyes. A pars plana vitrectomy was performed OD with intravitreal injections of vancomycin (1 mg/0.1 ml), ceftazidime (2 mg/0.1 ml) and amphotericin B (7.5 μg/0.1 ml). Vitreous cultures grew Candida albicans, and the patient was treated with oral diflucan (200 mg daily). The patient received five intravitreal injections of amphotericin B (5 μg/0.1 ml) in the vitrectomised right eye and three in the non‐vitrectomised left eye over 3 weeks for persistent active lesions. At the most recent examination, 12 weeks after presentation, the patient's vision was 20/20 OD and 20/50 OS.

Case 2

A 37‐year‐old homeless male intravenous drug user reported a 3‐month history of decreased vision, eye pain and floaters in his right eye. His medical history was significant for HIV (recent CD4 count of 799 cells/mm3) and hepatitis C. The patient reported the use of preserved lemon juice to dissolve crack‐cocaine for injection.

His visual acuity was hand motions OD and 20/20 OS. Dilated fundus examination of the right eye was obscured by 3+ vitritis, but there appeared to be a large infiltrate in the macula. A vitreous aspiration was performed, with intravitreal injections of ceftazidime (2 mg/0.1 ml) and vancomycin (1 mg/0.1 ml) in the right eye. The vitreous aspire grew C albicans. Amphotericin B (5 mg/0.1 ml) was injected, and the patient was admitted for intervenous flucanozole (400 mg four times a day). Blood cultures and ECG were negative. A therapeutic vitrectomy with a lensectomy was performed. Ten days postoperatively, the patient's vision improved to 20/400 OD, with a decrease in inflammation and resolution of the infiltrate, whereas the left eye was unchanged. The patient was unfortunately lost to follow‐up.


Potential sources of infection in injecting drug users are the impure drug itself, poorly disinfected skin at the site of injection, unsterile preparation of the drug, and/or contaminated needles or syringes. This report raises the possibility that the lemon juice used to dissolve crack‐cocaine might be another risk factor for fungal infection. In treating injecting drug users, ophthalmologists should inquire about the use of preserved juices. If used, this should raise the concern of fungal endophthalmitis. Furthermore, when an injecting drug user is infected with fungal endophthalmitis, it might be recommended to advise other users, who share the lemon juice, of the risk for endophthalmitis. Finally, public health efforts to decrease the morbidity of intervenous crack‐cocaine use should discourage users from dissolving crack‐cocaine in lemon juice. In fact, outreach programmes in certain inner cities are distributing packets of ascorbic acid to injecting drug users.


Funding: Unrestricted grant from Research to Prevent Blindness, New York, NewYork, USA RNK is a Heed Fellow and supported by the Heed Ophthalmic Foundation

Competing interests: None.

Informed consent was obtained for publication of the persons details in this report.


1. Santibanez S S, Garfein R S, Swartzendruber A. et al Prevalence and correlates of crack‐cocaine injection among young injection drug users in the United States, 1997‐1999. Drug Alcohol Depend 2005. 77227–233.233
2. Buchanan D , Tooze JA , Shaw S , et al Demographic, HIV risk behavior, and health status characteristics of “crack” cocaine injectors compared to other injection drug users in three New England cities. Drug Alcohol Depend 2006. 81221–229.229
3. Servant J B, Dutton G N, Ong‐Tone L. et al Candidal endophthalmitis in Glaswegian heroin addicts: report of an epidemic. Trans Ophthalmol Soc UK 1985. 104(Pt 3)297–308.308 [PubMed]
4. Newton‐John H F, Wise K, Looke D F. Role of the lemon in disseminated candidiasis of heroin abusers. Med J Aust 1984. 140780–781.781 [PubMed]

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