heroin and Botulism

Outbreaks of wound botulism are rare, but clinicians and health departments should maintain suspicion for signs, symptoms, and risk factors of wound botulism among persons who inject drugs in order to initiate treatment quickly. This report describes an outbreak of three wound botulism cases among persons in two adjacent counties who injected drugs. Provisional information about these cases was previously published in the CDC National Botulism Surveillance Summary. All three cases in this outbreak were laboratory-confirmed, including one case with detection of botulinum toxin type A in a wound culture sample taken 43 days after last possible heroin exposure. Findings highlight the delay in diagnosis which led to prolonged hospitalization and the persistence of botulinum toxin in one patient.

Topics: Botulism; Drug Users; Heroin; Humans; New Mexico; Substance Abuse, Intravenous; Wound Infection

People who inject drugs (PWID) are at an increased risk of wound botulism, a potentially fatal acute paralytic illness. During the first 6 months of 2015, a large outbreak of wound botulism was confirmed among PWID in Scotland, which resulted in the largest outbreak in Europe to date.. A multidisciplinary Incident Management Team (IMT) was convened to conduct an outbreak investigation, which consisted of enhanced surveillance of cases in order to characterise risk factors and identify potential sources of infection.. Between the 24th of December 2014 and the 30th of May 2015, a total of 40 cases were reported across six regions in Scotland. The majority of the cases were male, over 30 and residents in Glasgow. All epidemiological evidence suggested a contaminated batch of heroin or cutting agent as the source of the outbreak. There are significant challenges associated with managing an outbreak among PWID, given their vulnerability and complex addiction needs. Thus, a pragmatic harm reduction approach was adopted which focused on reducing the risk of infection for those who continued to inject and limited consequences for those who got infected.. The management of this outbreak highlighted the importance and need for pragmatic harm reduction interventions which support the addiction needs of PWID during an outbreak of spore-forming bacteria. Given the scale of this outbreak, the experimental learning gained during this and similar outbreaks involving spore-forming bacteria in the UK was collated into national guidance to improve the management and investigation of future outbreaks among PWID.

Topics: Adult; Analgesics, Opioid; Botulism; Disease Outbreaks; Drug Contamination; Female; Harm Reduction; Heroin; Heroin Dependence; Humans; Male; Middle Aged; Risk Factors; Risk Management; Scotland; Wound Infection; Young Adult

Since 2000 in the United Kingdom, infections caused by spore-forming bacteria have been associated with increasing illness and death among persons who inject drugs (PWID). To assess temporal and geographic trends in these illnesses (botulism, tetanus, Clostridium novyi infection, and anthrax), we compared rates across England and Scotland for 2000-2009. Overall, 295 infections were reported: 1.45 per 1,000 PWID in England and 4.01 per 1,000 PWID in Scotland. The higher rate in Scotland was mainly attributable to C. novyi infection and anthrax; rates of botulism and tetanus were comparable in both countries. The temporal and geographic clustering of cases of C. novyi and anthrax into outbreaks suggests possible contamination of specific heroin batches; in contrast, the more sporadic nature of tetanus and botulism cases suggests that these spores might more commonly exist in the drug supply or local environment although at varying levels. PWID should be advised about treatment programs, injecting hygiene, risks, and vaccinations.

Topics: Adult; Anthrax; Bacillus anthracis; Botulism; Clostridium; Clostridium botulinum; Clostridium Infections; Clostridium tetani; Disease Outbreaks; Drug Contamination; England; Female; Heroin; Humans; Incidence; Male; Scotland; Spores, Bacterial; Substance Abuse, Intravenous; Tetanus

Topics: Botulinum Antitoxin; Botulism; Diagnosis, Differential; Female; Heroin; Heroin Dependence; Humans; Injections; Middle Aged; Substance Abuse, Intravenous

Following the introduction of black tar heroin mainly from Mexico in the 1980s, cases of wound botulism dramatically increased in the western United States. Contamination with spores of Clostridium botulinum of black tar heroin occurs along the distribution line. The heating of heroin powder to solubilize it for subcutaneous injection ("skin popping") does not kill the spores. The spores germinate in an anaerobic tissue environment and release botulinum toxin type A or B. Unless skin abscesses are found in the patient, the clinical diagnosis is often challenging. Facilitation of the compound muscle action potential by repetitive nerve stimulation at 20 to 50 Hz is an important and rapid diagnostic test. Definite diagnosis is made by detection of botulinum toxin in serum or isolation of C botulinum from the abscess. Early treatment with equine ABE botulinum antitoxin obtained from the Centers for Disease Control and Prevention often shortens the time on a ventilator.

Topics: Action Potentials; Animals; Botulinum Toxins; Botulism; Clostridium botulinum; Electrodiagnosis; Female; Heroin; Humans; Injections, Subcutaneous; Male; Wound Infection

5 heroin addicts (aged 31-44 years; 1 female, 4 men) presented with a history of blurred vision and diplopia followed by dysarthria. 3 of the patients also developed respiratory failure requiring long-term ventilatory support. Physical examination revealed cranial nerve deficits and abscesses at injection sites in 3 of them.. In 4 patients wound botulism was diagnosed on the basis of symptoms, course of the illness and response to specific treatment. Clostridium botulinum was grown from wound swab in one patient.. Two of the patients, having been injected with antitoxin immediately after admission, were discharged almost symptom-free after only a few days. Adjuvant antibiotics and, in 3 patients, surgical débridement of the abscesses were needed.. Progressive cranial nerve pareses in addicts who inject drugs intravenously or intramuscularly should raise the suspicion of wound botulism and require hospitalization. While indirect demonstration of toxin supports the diagnosis, false-negative results are common.

Topics: Adult; Anti-Bacterial Agents; Botulinum Antitoxin; Botulism; Clostridium botulinum; Debridement; Diagnosis, Differential; Female; Follow-Up Studies; Germany; Heroin; Heroin Dependence; Humans; Injections, Intramuscular; Injections, Intravenous; Male; Middle Aged; Time Factors; Treatment Outcome; Wound Infection

Wound botulism is a rare infectious disease due to neurotoxin release from the anaerobic, spore-forming bacterium Clostridium botulinum that is becoming an ever more frequent complication of parenteral drug abuse in the Western world. Before the year 2000, no such cases had been reported in the UK and Ireland, but since then the number of proven and suspected cases of wound botulism occurring in parenteral drug users has increased markedly. The diagnosis is often difficult, based on a high degree of clinical suspicion and if not considered in the initial differential diagnosis, then considerable delays in treatment may result. This is the case report of a male heroin user who presented three times to an Emergency Department in the UK before a diagnosis of wound botulism was made and treatment commenced. It is important that emergency clinicians are aware of the possibility of wound botulism in parenteral drug users that present with unusual neurological or respiratory symptomatology.

Topics: Adult; Botulinum Antitoxin; Botulism; Clostridium botulinum; Heroin; Humans; Injections, Subcutaneous; Male; Substance Abuse, Intravenous

There are three main, naturally occurring, epidemiological types of botulism: food-borne, intestinal colonization (infant botulism) and wound botulism. The neurological signs and symptoms are the same for all three epidemiological types and may include respiratory paralysis. Wound botulism is caused by growth of cells and release of toxin in vivo, is associated with traumatic wounds and abscesses and has been reported in drug users, such as those injecting heroin or sniffing cocaine. Up to the end of 1999 there were no confirmed cases of wound botulism in the UK. Between the beginning of 2000 and the end of December 2002, there were 33 clinically diagnosed cases of wound botulism in the UK and Ireland. All cases had injected heroin into muscle or by 'skin popping'. The clinical diagnosis was confirmed by laboratory tests in 20 of these cases. Eighteen cases were caused by type A toxin and two by type B toxin.

Topics: Adult; Antibodies, Bacterial; Botulinum Toxins; Botulinum Toxins, Type A; Botulism; Clostridium botulinum; Diagnosis, Differential; Female; Heroin; Humans; Ireland; Male; Middle Aged; Substance Abuse, Intravenous; United Kingdom; Wound Infection

Wound botulism in 7 heroin 'skin poppers' produced ophthalmoplegia and descending paralysis. Rapid recovery occurred in 2 who received the antitoxin within the fourth day of symptom onset. A poor outcome was seen in 4 who received the antitoxin after the eighth day of symptoms and 1 who did not receive the antitoxin. Early antitoxin administration is important in achieving a favorable outcome.

Topics: Abscess; Adult; Botulinum Antitoxin; Botulism; Female; Heroin; Humans; Injections, Subcutaneous; Male; Middle Aged; Skin Diseases; Treatment Outcome

During August 22-26, 2003, four injection-drug users (IDUs) in Yakima County, Washington, sought medical care at the same hospital with complaints of several days of weakness, drooping eyelids, blurred vision, and difficulty speaking and swallowing. All four were regular, nonintravenous injectors of black tar heroin (BTH), and one also snorted BTH. This report summarizes the investigation of these cases, which implicated wound botulism (WB) as the cause of illness.

Topics: Adult; Botulism; Female; Heroin; Heroin Dependence; Humans; Male; Middle Aged; Substance Abuse, Intravenous; Washington; Wound Infection

A 32-year old male drug user presented with diplopia, ataxia and general weakness. The patient had abscesses on arms and legs at injection sites, bilateral ptosis, a bifacial weakness, nasal speech, severely reduced ability to raise his arms and a positive Trendelelenburg sign with normal motor neuron reflexes and normal sensation.. The haematological values indicated a hypochromic, microcytic anaemia (12,1 mg/dl), a slight leuko (10,8 G/L) - and thrombocytosis (582G/l) with elevated erythrocyte sedimentation rate (74 mm/h), and a reduced prothrombin time (67%). The HIV test was negative. The MRI scan of the brain and the bacterial, serological and cytological results of a lumbar puncture were normal. In the bloodculture no bacterial growth and no botulinum toxin was found. In a culture of the wound material grew coagulase-negative staphylococcus and Clostridium perfringens, diagnosed with PCR. The serum anti-acethylcholine antibodies were negative. The motor-nerve conduction test with repetitive stimulation of the ulnari nerve with a 3 Hz trigger showed no change in the amplitude, while a 20 Hz trigger showed an increment up to 160 %.. Another possible diagnosis was excluded through MRI, CSF and serum examination. The typical presentation of a rapidly progressive descending paralysis without loss of sensation and the typical motor-nerve conduction disorder of a presynaptic block established the diagnosis of wound botulism. This was treated immediately by surgical removal of wound debris, antitoxin- and penicillin therapy. After 28 days the patient left the hospital with slight residual problems. He had been admitted to the intensive care unit for a short period only and intubation was not necessary at any time.. After exclusion of any other possible diagnosis, it is possible to establish an early diagnosis of injection related wound botulism by its typical symptoms and signs. These are presented as wound abcesses at intramuscular drug injection sites together with rapidly progressive descending paralysis with preserved sensation. Treatment consists of surgical excision of wound debris combined with antitoxin and penicillin administration in order to prevent a possible build-up of residues. Early diagnosis and associated therapy overcome the necessity of intubation and prolonged intensive care.

Topics: Adult; Botulinum Antitoxin; Botulism; Diagnosis, Differential; Heroin; Heroin Dependence; Humans; Injections, Intramuscular; Injections, Intravenous; Male; Penicillins; Time Factors; Wound Infection

Clostridium novyi has recently been identified as the causative organism responsible for the deaths of 35 heroin addicts who had injected themselves intramuscularly. We present two heroin addicts who developed C. botulinum infection following intramuscular or subcutaneous injection of heroin. Like C. novyi, this grows under anaerobic conditions and clinical presentation may be similar; however, descending motor or autonomic signs are invariably present in botulism. The prognosis is good if the diagnosis is made early and appropriate treatment commenced.

Topics: Adult; Botulinum Antitoxin; Botulism; Diagnosis, Differential; Female; Heroin; Humans; Male; Penicillin G; Penicillins; Respiratory Insufficiency; Substance Abuse, Intravenous; Treatment Outcome; Wound Infection

Topics: Adult; Botulism; Female; Heroin; Heroin Dependence; Humans; Injections, Intramuscular; Injections, Subcutaneous; United Kingdom; Wound Infection

Topics: Adult; Botulinum Antitoxin; Botulism; Heroin; Humans; Male; Narcotics; Patient Care Team; Substance Abuse, Intravenous

Topics: Adult; Botulism; Female; Heroin; Humans; London; Risk Assessment; Substance Abuse, Intravenous; Wounds and Injuries

Topics: Adult; Botulinum Antitoxin; Botulism; Debridement; Head; Heroin; Humans; Male; Paresis; Substance Abuse, Intravenous; Wound Infection

Topics: Adult; Botulism; Clostridium botulinum; Female; Heroin; Humans; Substance Abuse, Intravenous; Wound Infection

Wound botulism (WB) is a potentially lethal, descending, flaccid, paralysis that results when spores of Clostridium botulinum germinate in a wound and elaborate neurotoxin. Since 1988, California has experienced a dramatic increase in WB associated with injecting "black tar" heroin (BTH), a dark, tarry form of the drug.. To identify risk factors for WB among injecting drug users (IDUs).. Case-control study based on data from in-person and telephone interviews.. Case patients (n=26) were IDUs who developed WB from January 1994 through February 1996. Controls (n=110) were IDUs newly enrolled in methadone detoxification programs in 4 counties.. Factors associated with the development of WB.. Among the 26 patients, the median age was 41.5 years, 15 (58%) were women, 14 (54%) were non-Hispanic white, 11 (42%) were Hispanic, and none were positive for the human immunodeficiency virus. Nearly all participants (96% of patients and 97% of controls) injected BTH, and the mean cumulative dose of BTH used per month was similar for patients and controls (27 g and 31 g, respectively; P=.6). Patients were more likely than controls to inject drugs subcutaneously or intramuscularly (92% vs 44%, P<.001) and used this route of drug administration more times per month (mean, 67 vs 24, P<.001), with a greater cumulative monthly dose of BTH (22.3 g vs 6.3 g, P<.001). A dose-response relationship was observed between the monthly cumulative dose of BTH injected subcutaneously or intramuscularly and the development of WB (chi2 for linear trend, 26.5; P<.001). In the final regression model, subcutaneous or intramuscular injection of BTH was the only behavior associated with WB among IDUs (odds ratio, 13.7; 95% confidence interval, 3.0-63.0). The risk for development of WB was not affected by cleaning the skin, cleaning injection paraphernalia, or sharing needles.. Injection of BTH intramuscularly or subcutaneously is the primary risk factor for the development of WB. Physicians in the western United States, where BTH is widely used, should be aware of the potential for WB to occur among IDUs.

Topics: Adult; Aged; Botulism; California; Case-Control Studies; Female; Heroin; Humans; Likelihood Functions; Male; Middle Aged; Multivariate Analysis; Regression Analysis; Risk Factors; Statistics, Nonparametric; Substance Abuse, Intravenous; Wound Infection

Topics: Botulism; Heroin; Humans; Substance Abuse, Intravenous; Wound Infection

Topics: Adult; Botulism; Female; Heroin; Humans; Male; Substance Abuse, Intravenous; Wound Infection

The incidence of wound botulism is increasing and the epidemiology of the disease is changing. The majority of new cases are associated with injection drug use, in particular, the use of Mexican black tar heroin. This case report and discussion of wound botulism illustrate the following important points: Dysphagia, dysphonia, diplopia, and descending paralysis, in association with injection drug use, should alert the treating physician to the possibility of wound botulism. In such patients, the onset of respiratory failure may be sudden and without clinically obvious signs of respiratory weakness. For the reported patient, maximum inspiratory force measurements were the only reliable indicator of respiratory muscle weakness. This is a measurement not routinely performed in the ED, but may prove essential for patients with suspected wound botulism. To minimize the effect of the botulinum toxin and to decrease length of hospital stay, antitoxin administration and surgical wound debridement should be performed early.

Topics: Botulism; Combined Modality Therapy; Heroin; Heroin Dependence; Humans; Injections, Intravenous; Injections, Subcutaneous; Male; Middle Aged; Respiratory Insufficiency; Treatment Outcome

Topics: Adult; Botulism; Clostridioides difficile; Female; Heroin; Humans; Male; Pregnancy; Pregnancy Complications; Substance Abuse, Intravenous; Wound Infection

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.

Topics: Adult; Botulism; Clostridioides difficile; Female; Heroin; Humans; Injections, Subcutaneous; Male; Pregnancy; Substance-Related Disorders; Wound Infection

Wound botulism is a rare infectious and toxicologic complication of trauma and i.v. drug abuse. Only 39 cases have been reported in detail in the English literature. This case report describes a patient with wound botulism who presented to four medical facilities before receiving definitive diagnosis and treatment. Although his history and physical examination were consistent with wound botulism, diagnosis and therapy were delayed because this rare disease was not considered initially in the differential diagnosis. Wound botulism should be considered in trauma patients and i.v. drug abusers who present with cranial nerve palsies and descending paresis.

Topics: Abscess; Adult; Botulism; Clostridium botulinum; Diagnostic Errors; Heroin; Humans; Male; Skin Diseases, Bacterial; Substance-Related Disorders; Wound Infection