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Wound botulism in the UK

2001; Elsevier BV; Volume: 357; Issue: 9251 Linguagem: Inglês

10.1016/s0140-6736(05)71338-6

1474-547X

BS Athwal, AN Gale, MM Brett, BD Youl,

Pain Mechanisms and Treatments

M Jensenius and colleagues (Sept 30, p 1160)1Jensenius M Løvstad RZ Dhaenens G Rørvik LM A heroin user with a wobbly head.Lancet. 2000; 356: 1160Summary Full Text Full Text PDF PubMed Scopus (16) Google Scholar report a heroin user in Norway who presented with a wobbly head and developed respiratory failure because of wound botulism, although they could not identify the toxin type by mouse bioassay. We saw in the UK, a woman aged 34 years who presented in May, 2000, with pneumonia and respiratory failure requiring intubation and mechanical ventilation for 5 weeks due to toxin type A. Our patient had regularly injected heroin subcutaneously or intramuscularly and 6 months previously had developed injection-related abscesses in both buttocks. On admission she had variable ptosis, an external opthlamoplegia, sluggish papillary responses and severe proximallimb and respiratory-muscle weakness. Tendon reflexes were present throughout with flexor plantar responses. Blood electrolytes and creatine kinase were normal and serum acetylcholine receptor and HIV antibodies were negative. Peripheralnerve conduction was normal but compound muscle action potentials were reduced. Electromyography showed profuse fibrillation and jitter with no incremental response on posttetanic repetitive nerve stimulation. Cerebral spinal fluid was normal. Intravenous edophonium resulted in partial improvement in the ptosis and ophthalmoplegia but no improvement in limb or respiratory-muscle weakness. She had several skin lesions on the buttocks related to old injection sites, adjacent to one of which was a fluctuant abscess. We diagnosed botulism and treated her with specific antitoxin and high-dose benzylpenicillin. Mouse bioassay confirmed the presence of Clostridium botulinum toxin type A in blood, and toxin-A-producing organisms were grown from pus aspirated from the buttock abscess. The patient made a full recovery. The most common form of botulism seen in the UK results from the ingestion of toxin in food with the last reported cases, in 1998, being caused by contaminated home-preserved mushrooms.2Roberts EJ Wales JM Brett MM Bradding P Cranial-nerve palsies and vomiting.Lancet. 1998; 352: 1674Summary Full Text Full Text PDF PubMed Scopus (12) Google Scholar Wound botulism has been reported in injecting drug users in the USA, who used Mexican black tar heroin.3Passaro DJ Werner SB McGee J et al.Wound botulism associated with black tar heroin among injecting drug users.JAMA. 1998; 279: 859-863Crossref PubMed Scopus (191) Google Scholar Similar cases have been reported from Norway and Switzerland, but those and our case were associated with this form of heroin. Drug users injecting subcutaneously or intramuscularly seem susceptible to clostridial infections; several in the UK were due to C novyi.4Christie B Gangrene bug "killed" 35 heroin users.BMJ. 2000; 320: 1690Crossref PubMed Scopus (14) Google Scholar Cases are, however, rare. Other people who frequently inject, such as patients with insulin-dependent diabetes, do not seem prone to this disorder. C botulinum is an obligate anaerobe and spores are unlikely to germinate in healthy tissue, so infection probably occurred from inoculation of tissue devitalised by recent abscesses. Wound botulism should be considered in patients with features compatible with botulism, if there is a recent history of abscess, and when epidemiological investigation suggests that a food-borne cause is unlikely. We agree with Jensenius and colleagues that early treatment with antitoxin and eradication of abscesses are important measures in management but, because of the rarity of botulism, the diagnosis in isolated cases might be delayed.