Wound botulism following intravenous methamphetamine use

Abstract

OBJECTIVE: Wound botulism is rarely encountered in developed countries. We report a case of wound botulism in an intravenous drug user. Early clinical recognition and treatment with antitoxin is essential to reduce morbidity and mortality in wound botulism [1,2]. CASE REPORT: A 35-year-old male presented to a tertiary Emergency Department with a two-day history of nonspecific neurological symptoms. He complained of lethargy, difficulty swallowing, increased salivation, and numbness to his mouth. He last injected methamphetamine intravenously 2 days previously, after which his symptoms began. On initial assessment, he was afebrile, blood pressure 130/70mmHg, with oxygen saturations 100% on room air. A neurological examination demonstrated cranial nerve deficits with ptosis, abnormal gag reflex, with difficulty swallowing. He was alert with a Glasgow Coma Score (GCS) of 15. There was superficial thrombophlebitis of the left antecubital fossa, the injection site. A blood culture was obtained. Neuroimaging was normal. The following day, the patient developed progressive neurological features with bilateral tongue weakness, absent gag reflex, bilateral ophthalmoplegia with gaze paresis, increasing drowsiness and respiratory failure requiring intubation and ventilation. The blood culture demonstrated growth of Clostridium botulinum on day 4. The patient was treated with penicillin and botulinum antitoxin. There was gradual improvement in his neurological status and he was extubated after 14 days, and discharged clinically well 26 days later. Clostridium botulinum Type B was detected by public health on his drug paraphernalia. CONCLUSIONS: Wound botulism is most commonly implicated with black tar heroin [3,4]. Botulinum toxin type A is the most common toxin type in wound botulism [3]. Neurological signs of botulism such as ptosis and altered phonation might be interpreted as mental status changes associated with drug use but botulism needs to be considered in intravenous drug users with focal neurological signs.