Early invasive pulmonary aspergillosis in a leukemia patient linked to aspergillus contaminated marijuana smoking

46-year-old patient with acute myeloid leukemia (AML) whose disease manifested as fever, chills and dry cough is reported here. Despite broad antibiotic coverage he remained acutely ill with spiking fever, shaking chills, and hypoxemia. His initial chest radiograph was normal but chest computed tomography (CT) scan disclosed bilateral focal infiltrates. Hypoxemia and severe thrombocytopenia precluded invasive diagnostic procedures. A thorough epidemiological investigation revealed that before becoming acutely ill the patient smoked daily tobacco mixed with marijuana from a "hookah bottle". While waiting for tobacco and "hookah water" cultures, we started antifungal therapy. Resolution of fever and hypoxemia ensued after 72 hours. Tobacco cultures yielded heavy growth of Aspergillus species. We suggest that habitual smoking of Aspergillus-infested tobacco and marijuana caused airway colonization with Aspergillus. Leukemia rendered the patient immunocompromised, and allowed Aspergillus to infest the lung parenchyma with early occurrence of invasive pulmonary aspergillosis. Physicians should be aware of this potentially lethal complication of "hookah" and marijuana smoking in immunocompromised hosts.