Botulism

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.

Of the four patients, two were men; the patients had a median age of 38 years (range: 31-50 years). Two patients were married and used drugs at the same time and in the same setting as the third patient; however, they did not share injection equipment with the third patient. The fourth patient had no social connection with the other three. All four purchased BTH from the same dealer. No meals or gatherings were attended by all of the patients, and no single common food item had been eaten recently, including no home canned or vacuum-packed foods. On examination, all had cranial nerve palsies, including ptosis, ophthalmoplegia, dysarthria, and diminished or absent gag reflex, and upper extremity weakness, clear sensorium, and no sensory deficits. Three had infected wounds from drug injections. In two patients who went simultaneously to an emergency department, botulism was suspected immediately by the admitting physician, who alerted public health officials promptly and sought antitoxin. Antitoxin was administered within 14-24 hours of admission for all patients. Wound care and treatment with intravenous ampicillin/sulbactam was initiated within 12 hours for the three patients with wounds.

Two patients, both subcutaneous IDUs, progressed to respiratory failure despite antitoxin administration and continue to require mechanical ventilation. One is improving in strength and might progress to extubation. The other probably will require long-term ventilatory support. The third and fourth patients, both intramuscular IDUs with milder presentations, were discharged with minimal residual weakness 17 and 9 days after admission, respectively.

At the Washington State Public Health Laboratories, botulinum toxin type A was detected by mouse bioassay in serum specimens obtained from the first two patients, but not from serum of the third and fourth patients. Toxin assays and anaerobic stool cultures from all patients failed to demonstrate boadinum toxin or Clostridium growth, respectively. Anaerobic culture of a wound specimen from the third patient is pending, and a nasal aspirate from the fourth patient was negative. Injection paraphernalia and a sample of BTH have been submitted to CDC for further testing for toxigenic Clostridium bacteria.

Local and state public health officials have notified healthcare providers and acute-care facilities to increase suspicion of WB in IDUs and have emphasized the importance of prompt recognition of WB, early antitoxin administration, and appropriate wound treatment (1). Outreach staff are working through a needle exchange and other venues to inform IDUs about the outbreak, the need to seek immediate care if affected, and the ongoing risks for using BTH.

Acknowledgments

The following persons assisted with the investigation and reporting of this outbreak: J Ricking, MD, Yakima Valley Farmworkers Clinic, Toppenish; C Whittlesey, MD, Wapato; C Contreras, J Vargas, B Andrews, D Flodin-Hursh, P Benitez, M Patnode, D Klukan, MSPH, Yakima Health District; R Graham, Indian Health Svc, Toppenish; M McDowell, Washington State Dept of Health; J Jones, MD, Northwest Portland Area Indian Health Board, Portland.

Editorial Note: Clinical findings, laboratory results, and epidemiologic features of this outbreak reflect previous descriptions of WB in IDUs (2-4). BTH might be contaminated during the "cutting" process through incorporation of sporeladen adulterants such as dirt or boot polish (3,4). Heating the drug does not inactivate clostridial spores, and safe injection practices that protect against bloodborne infection do not reduce the risk for WB. In January 2002, a cluster of seven cases of necrotizing fasciitis occurred among IDUs in Yakima County (5). The route of injection was reported as subcutaneous in three of the patients, two of whom died. Clostridia spp. were identified in specimens from these three cases; in one case, subtyping was carried out, and the isolate was identified as Clostridium sordelii. These persons were in the same IDU network as those in the current botulism outbreak.

References

(1.) Sandrock CE, Murin S. Clinical predictors of respiratory failure and long-term outcome in black tar heroin-associated wound botulism. Chest 2001;120:562-6.

(2.) CDC. Wound botulism--California, 1995. MMWR 1995;44:889-92.

(3.) Werner SB, Passaro D, McGee J, et al. Wound botulism in California, 1951-1998: recent epidemic in heroin injectors. Clin Infect Dis 2000;31:1018-24.

(4.) Passaro DJ, Werner SB, McGee J, et al. Wound botulism associated with black tar heroin among injecting drug users. JAMA 2000;279:859-63.

(5.) Yakima Health District. Fatal soft tissue infections in drug injectors. YHD Bulletin 2002; 1:1,4.

C Spitters, MD, Yakima Health District; J Moran, MD, Yakima Valley Farmworkers Clinic; D Kruse, MD, Yakama Indian Health Clinic, Toppenish; N Barg, MD, Yakima; M Leslie, DVM, J Hofmann, MD, Washington State Dept of Health. M Moore, MD, Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases; G Macgregor-Skinner, BVSc, EIS Officer, CDC.

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