Wound Botulism Associated with Parenteral Cocaine Abuse -- New York City

CDC recently received its first report of botulism directly associated with drug abuse. The patient was admitted to a New York hospital with symptoms of botulism several days after attempting to inject cocaine intravenously. Clostridium_botulinum the causative organism, usually associated with the consumption of contaminated food, was isolated from specimens obtained from the patient after he was admitted to the hospital.

A 30-year-old male drug abuser in New York City was hospitalized January 2, 1982, 3 days after the onset of progressive neurologic symptoms that included dysphonia, dysarthria, dysphagia and dry mouth, dyspnea, and bilateral arm weakness. Physical examination revealed a small subcutaneous, non-erythematous, non-tender, cyst-like structure on the left arm at the site of an attempt, 2 weeks earlier, to inject cocaine intravenously. Also noted were bilateral ptosis, bilateral abducens paralysis, facial diplegia, dysarthric speech, inability to protrude the tongue, and bilateral arm weakness that was more pronounced in the proximal than the distal musculature. Sensation was normal to all modalities, and deep tendon reflexes were preserved.

Administration of intravenous edrophonium chloride (Tensilon) relieved ptosis and improved extraocular movements and grip strength. Lumbar puncture revealed 5 white blood cells (WBCs)/uL, a protein level of 17mg/dL, and a cerebrospinal fluid glucose level of 51 mg/dL. Median nerve conduction velocity and F-responses were normal, but the amplitude of the evoked muscle-action potential was low. Repetitive stimulation at 10 Hertzogs increased the muscle action potential by 50%. On the basis of these results, a preliminary diagnosis of botulism was made.

Muscle strength and vital capacity deteriorated progressively, and the patient required respiratory support. Cultures of stool and gastric aspirate obtained on admission did not reveal C._botulinum; stool and serum were negative for C._botulinum toxin in a mouse bioassay. An aspirate of the subcutaneous cyst yielded anaerobic, gram-positive, gas-forming bacilli; isolates were positive for type B botulinum toxin in a mouse bioassay.

Questioning the patient and his family failed to implicate any food source, and no cocaine was available from the sample used by the patient 2 weeks earlier. He had not injected the drug in the company of others, and he reported that none of his friends were similarly ill.

The abscess was excised on the 8th hospital day, and the patient was treated with intravenous penicillin (9 million units per day) for 10 days. Botulinum antitoxin was not administered. Because myasthenia gravis, toxic neuropathy, and the descending variant of Guillain-Barre syndrome were considered as diagnoses, the patient was given daily plasma exchanges. Limb and extraocular palsy and vital capacity began to improve, and respiratory support was removed on the 17th hospital day. The patient's dysphagia remains the most severe symptom; however, he continues to improve daily. Reported by S Rapoport, MD, PB Watkins, MD, S Saul, MD, James Salzer, MD, R Cooper, MD, R Roberts, MD, L Drusin, MD, New York Hospital, S Shahidi, PhD, R Clark, Bureau of Laboratories; V Paul, S Friedman, MD, New York City Dept of Health, R Rothenberg, MD, State Epidemiologist, New York State Dept of Health; H Janiger, US Food and Drug Administration; Bacterial Diseases Div, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Since 1943, when the first report of wound botulism was received, 27 cases have been reported to CDC; 22 involved males. The mean age was 22.7 years (range 6-44). Fifteen cases were associated with type A, 5 with type B, 1 with mixed A and B, and the remainder were undetermined as to type. Twenty cases occurred in states west of the Mississippi, with 10 in California alone. This report from New York City represents the first case involving a drug abuser and suggests that botulism should be considered in the differential diagnosis when a patient with a history of drug abuse is seen for neurologic and respiratory symptoms. The relatively minor wound, the negative stool culture, and negative assays of stool and serum for toxin observed for this patient emphasize the difficulties associated with recognizing cases of wound botulism.

There is no evidence that plasma exchanges are useful in treating persons with any form of botulism. In addition, because of the small number of recognized cases, it has not been possible to evaluate the efficacy of antibiotics or antitoxin as therapy for wound botulism. In 1 review of 9 wound-botulism cases, antitoxin was administered to 4 patients; 3 of these patients survived (1).

References

1. Merson MH, Dowell VR, Jr. Epidemiologic, clinical and laboratory aspects of wound botulism. N Engl J Med 1973;289:1005-10.

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