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Wound Botulism -- California, 1995

During January-November 1995, a total of 19 laboratory-confirmed cases of wound botulism were reported to the California Department of Health Services (CDHS); of these, 13 had occurred since August. Since 1990, the number of wound botulism cases reported annually in California has increased steadily (one case in 1990, two in 1991, three in 1992, four in 1993, and 11 in 1994). All cases except one since 1991 have occurred in injecting-drug users, and many involved subcutaneous injection or "skin popping" of black tar heroin. This report summarizes the findings of the investigation of two cases. Case 1

On September 23, a 44-year-old male user of black tar heroin developed an abscess on his right arm, which was treated unsuccessfully with cephelexin and ciprofloxacin; on September 29, the abscess was incised and drained. On October 1, he was examined at a local emergency department (ED) because of slurred speech and was released.

On October 3, he sought care in the ED of a community hospital in Yolo County because of difficulty swallowing, which progressed to slurred speech, blurred vision, neck and arm weakness, and shortness of breath. Findings on physical examination included ophthalmoplegia; ptosis; and weakness of his facial, sternocleidomastoid, and deltoid muscles. Examination of a sample of his cerebrospinal fluid detected a marginally elevated protein level (50 mg/dL). A "Tensilon{Registered} * test" (intravenous administration of edrophonium bromide to improve strength) was negative, and electromyography was not performed. Despite treatment with intravenous gamma globulin for suspected Guillain-Barre syndrome, weakness progressed, and on October 4, he required mechanical ventilation. On October 5, the diagnosis of wound botulism was considered, and CDHS was consulted. Two vials of botulinal antitoxin were released by CDHS and administered to the patient; in addition, treatment with 12 million units of penicillin daily was initiated.

A serum specimen obtained from the patient on October 4 was positive for type A botulinal toxin by mouse bioassay. No tissue from the abscess could be obtained for culture. The patient was discharged on November 21. Case 2

On September 25, a 30-year-old pregnant woman who reported last skin popping black tar heroin on September 24 sought care at an ED in Ventura County because of a sore throat and the sensation of "heavy eyelids." An upper respiratory tract infection was diagnosed, and she was released. On September 27, she developed difficulty swallowing and speaking and was admitted to a community hospital for evaluation. During the 12 hours following admission, she developed ophthalmoplegia and profound, symmetric, proximal paralysis of arms and legs, affecting her arms more than her legs; she subsequently required mechanical ventilation. A Tensilon{Registered} test was negative. Electromyography with repetitive motor-nerve stimulation at 10 Hz increased the muscle action potential by 17%. Lumbar puncture could not be performed.

On September 29, she underwent wide excision of multiple abscesses on her left leg. Botulism was suspected; CDHS was consulted and released two vials of antitoxin for administration to the patient. Treatment with high-dose penicillin was initiated.

Tissue and serum specimens obtained from the patient were positive for type A botulinal toxin by mouse bioassay, and histochemical staining of an excised abscess indicated the presence of spores and vegetative cells consistent with Clostridium botulinum. Culture of tissue from the wound yielded C. botulinum type A. On November 21, the patient was discharged from the hospital; her baby, who was delivered by cesarean section at 34 weeks on November 11, remained in intensive care on December 7.

Reported by: M Gollober, MD, RA Beyer, MD, Woodland Memorial Hospital, S Kwan, RO Bates, MD, Yolo County Health Dept, Woodland; H Oster, MD, Community Memorial Hospital, M Billimek, SE Matson, G Feldman, MD, Ventura County Health Dept, Ventura; R Bryant, J McGee, SB Werner, MD, CA Glaser, MD, DJ Vugia, MD, SH Waterman, MD, State Epidemiologist, California Dept of Health Svcs. Div of Field Epidemiology, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: Wound botulism, first described in association with traumatic injury, is a rare illness that occurs after spores of C. botulinum have germinated in a wound and produced botulinal toxin, resulting in flaccid paralysis (1). Wound botulism attributable to drug injection was first reported in 1982 in New York City (2); since then, such cases have been reported only sporadically. However, wound botulism occurred in 11 (21%) of the 53 botulism cases among adults reported to CDC in the United States in 1994, and all occurred among injecting-drug users in California.

Black tar heroin is dark and gummy. The drug available in California is believed to be processed in facilities close to the source of opium poppies grown in several states in Mexico. The final product often contains adulterants as well as diluents (e.g., sugar) to increase bulk. The use of black tar heroin is believed to be increasing and, since 1993, has supplanted traditional forms of heroin in California and other western states. However, it is unknown whether the increase in cases of wound botulism reflects increased supply of the drug, a change in its manufacture and distribution, or a change in drug-using behavior.

Skin popping of heroin is common among chronic users who are either unable or reluctant to inject the drug intravenously. Unlike botulinal toxin, which is inactivated by heat, spores of C. botulinum -- which could be in the heroin or in the liquid (usually water) with which the heroin is dissolved -- are not destroyed by heating the heroin/liquid mixture. Spores inoculated into subcutaneous tissue -- either from the drug or from the skin after inadequate skin disinfection -- can germinate and produce toxin.

Botulism should be suspected in patients with acute onset of flaccid paralysis with ophthalmoplegia, ptosis, or other cranial nerve dysfunction, particularly when the paralysis is descending, symmetric, and associated with a normal cerebrospinal fluid protein level. A history of drug injection or a food history that does not identify a probable source for foodborne botulism should prompt consideration of wound botulism and elicitation of a thorough history and physical examination for evidence of cellulitis or abscess. A meticulous physical examination is necessary because wounds containing C. botulinum may be small and initially unnoticed. Inspection of the intranasal septum and paranasal sinuses also may disclose a focus of C. botulinum infection in persons who snort cocaine (3). The diagnosis is supported by either conventional electromyography showing potentiation after supramaximal stimulation at 20-50 Hz, or single-fiber electromyography showing increased jitter and blocking (4). A diagnosis of myasthenia gravis would be supported by improvement in muscle function after the administration of edrophonium bromide (Tensilon{Registered}). Initial treatment decisions should not necessarily await neurologic test results.

Both risk for death and duration of hospitalization can be reduced by prompt administration of botulinal antitoxin (5). The administration of antitoxin is not contraindicated by pregnancy. Wounds suspected of being contaminated with C. botulinum should be widely debrided and irrigated, ideally after the administration of botulinal antitoxin. Penicillin, 10-20 million units per day, is considered the antibiotic of choice, although its efficacy has not been determined (6). Mechanical ventilation is the main supportive therapy for treatment of severe botulism.

Because of the increase in wound botulism cases, CDHS has publicized this problem through press releases and provided informational materials for county health officials, ED physicians, and community-based organizations offering outreach to drug users. Clinically suspected cases of botulism should be reported immediately to local or state public health agencies to facilitate

  1. laboratory confirmation of the diagnosis (using serum and tissue specimens for suspected wound botulism; stool and possibly serum specimens for suspected infant botulism; and food, serum, stool, and gastric aspirate specimens for suspected foodborne botulism);

  2. release of antitoxin, if clinically indicated; and 3) prompt investigation of all likely foodborne sources to identify and eliminate a suspected food source to protect other persons. In addition, injecting-drug users should be reminded of the health risks associated with illicit drug use, including the possibility of botulism.

If local and state officials are not available, CDC can be contacted directly (telephone {404} 639-2206, Monday through Friday, 8 a.m.-4:30 p.m. Eastern Time or {404} 639-2888 at other times). In California, health-care workers should contact CDHS (telephone {510} 540-2308), where consultation is available at all times for suspected botulism cases.

References

  1. Weber JT, Goodpasture HC, Alexander H, Werner SB, Hatheway CL, Tauxe RV. Wound botulism in a patient with a tooth abscess: case report and review. Clin Infect Dis 1993;16:635-9.

  2. CDC. Wound botulism associated with parenteral cocaine abuse -- New York City. MMWR 1982; 31:87-8.

  3. Kudrow DB, Henry DA, Haake DA, Marshall G, Mathisen GE. Botulism associated with Clostridium botulinum sinusitis after intranasal cocaine abuse. Ann Intern Med 1988;109:984-5.

  4. Cruz Martinez A, Anciones B, Ferrer MT, Diez Tejedor E, Perez Conde MC, Bescansa E. Electrophysiologic study in benign human botulism type b. Muscle Nerve 1985;8:580-5.

  5. Tacket CO, Shandera WX, Mann JM, Hargrett NT, Blake PA. Equine antitoxin use and other factors that predict outcome in type A foodborne botulism. Am J Med 1984;76:794-8.

  6. Bleck TP. Clostridium botulinum. In: Mandell GL, Douglas RG, Bennett JE, eds. Mandell, Douglas and Bennett's principles and practice of infectious diseases. 4th ed. Churchill Livingstone: New York, 1995:2178-81.

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