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      Wound botulism caused by Clostridium subterminale after a heroin injection

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          Abstract

          Botulism is caused by toxin production from many species of Clostridium, most commonly Clostridium botulinum as well as C. baratii and C. butyricum. Development of wound botulism is associated with injection drug users but has also been described in traumatic injuries with exposure to soil. A patient presented to the emergency department with a complaint of descending, progressive weakness. He recently reported skin popping with heroin injections. Heptavalent botulinum antitoxin was obtained from the [Center for Disease Control and Prevention (CDC)]. On hospital day seven, the anaerobic wound cultures resulted with growth of Clostridium subterminale.

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          Wound botulism associated with black tar heroin among injecting drug users.

          Antony Passaro, Chris McGee, William R. Mac. Kenzie … (1998)
          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.
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            Safety and Improved Clinical Outcomes in Patients Treated With New Equine-Derived Heptavalent Botulinum Antitoxin.

            Patricia A Yu, Neal H. Lin, Barbara Mahon … (2017)
            Botulism is a rare, life-threatening paralytic illness. Equine-derived heptavalent botulinum antitoxin (HBAT), the only currently available treatment for noninfant botulism in the United States, was licensed in 2013. No reports have systematically examined safety and clinical benefit of HBAT among botulism patients.
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              Isolation of Clostridium in human infections: evaluation of 114 cases.

              S Gorbach, H Thadepalli (1975)
              One hundred fifty-two strains of Clostridium were isolated from 144 patients over a 14-month-peroid. These included 23 recognized species and 23 strains that were unclassified. Soft tissues or abscesses yielded 84 strains of Clostridium. Intraabdominal sites predominated, but clostridia were recovered from empyema, carcinoma, frostbite with gas gangrene, muscle abscess, aortic graft, and brain abscess. Blood cultures yielded 65 strains of Clostridium from 49 patients, representing 0.3% of 16,314 blood cultures (or 2.6% of 2,168 positive cultures). Clostridium perfringens was most common in blood, accounting for 37 isolates (57%). Clostridial bacteremia was often unrelated to the clinical setting and was found in alcoholics with aspiration or Streptococcus pneumoniae pneumonia, pulmonary tuberculosis, empyema, meningococcemia, and infantile gastroenteritis. In 20 of the 49 patients (41%), aerobic or other anaerobic bacteria were cultured concurrently from the blood. Thus, clostridial bacteremia should be interpreted with caution since there may be little correlation with the patient's clinical condition.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Infect Dis Rep
                Journal ID (publisher-id): IDR
                Title: Infectious Disease Reports
                Publisher: PAGEPress Publications, Pavia, Italy
                ISSN (Print): 2036-7430
                ISSN (Electronic): 2036-7449
                Publication date (Electronic): 05 September 2018
                Publication date Collection: 05 September 2018
                Volume: 10
                Issue: 2
                Electronic Location Identifier: 7654
                Affiliations
                [1 ]Department of Pharmacy
                [2 ]Department of Emergency Medicine, Maricopa Integrated Health System, University of Arizona , Phoenix, AZ, USA
                Author notes
                Department of Pharmacy, Maricopa Medical Center, 2601 East Roosevelt Street, Phoenix, AZ 85008, USA. +1.602.344.5686 - +1.602.344.5565. aimee.mishler@ 123456mihs.org

                Contributions: PC was the main author who completed the first draft of all sections, excluding the abstract. AM was the author who was the primary editor for the abstract, introduction, and discussion sections and was the author who completed the second draft, excluding the abstract, + coordinated all correspondence between authors, was responsible for compiling each portion of the manuscript, and was responsible for formatting and submitting the manuscript. DQ was the final editor for all portions. AP-G was the author who completed the abstract and was the primary editor for the case report section.

                Conflicts of interest: the authors declare no conflicts of interests.

                Article
                DOI: 10.4081/idr.2018.7654
                PMC ID: 6176474
                SO-VID: 777b571a-614a-4fb6-882a-a65de5c9c2fb
                Copyright © ©Copyright P. A. Cook et al., 2018
                License:

                This work is licensed under a Creative Commons Attribution NonCommercial 4.0 License (CC BY-NC 4.0).

                History
                Date received : 24 February 2018
                Date revision received : 04 June 2018
                Date accepted : 14 June 2018
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 23, Pages: 3
                Categories
                Subject: Case Report

                Keywords: botulism,wound botulism,antitoxin,clostridium,clostridium subterminale
                Data availability:
                Keywords: botulism, wound botulism, antitoxin, clostridium, clostridium subterminale

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