Wound botulism associated with subcutaneous drug use

Wound botulism in drug users is a rare but important cause of weakness and neuropathy

Botulism has long been considered a foodborne infection, the causative agent, Clostridium botulinum usually being transmitted in preserved foods. Yet C botulinum is widely distributed in soil and may be transmitted through wounds. An important distinction is that infections from food are limited to the amount of toxin ingested whereas in infections from wounds the toxin can be produced in situ until infection is eliminated from the wound.1

A new mode of presentation is occurring in drug users, the organism entering at sites of subcutaneous injection. The first reported case due to subcutaneous injection was in New York in 1982.2 As drug use has increased so has the number of people exposed to C botulinum. Over 90% of cases of wound botulism have been reported in the United States (75% in California), with only a small number of cases in the United Kingdom and elsewhere in Europe. 1 3^–6

Botulism manifests as an acute descending paralysis, with involvement of autonomic and cranial nerves. C botulinum produces a potent exotoxin that binds irreversibly to the presynaptic membrane causing failure of transmission at the neuromuscular junction, autonomic ganglia, and parasympathetic nerve terminals. Diagnosis is based on clinical and neurophysiological findings, serology, and by identifying the organism or toxin. An antitoxin is available, but treatment remains largely supportive. We report a case of wound botulism in a subcutaneous heroin user who posed diagnostic difficulties.