Wound Botulism Associated With Drug Injection
Date: March 21, 2014
Since March 1, 2014, two highly suspect cases of wound botulism associated with black tar heroin injection have been reported in San Diego County. The two hospitalized cases are apparently unknown to each other and presented with wound infections and a recent history of skin popping black tar heroin. Other symptoms included diplopia, bilateral ptosis, bilateral extraocular palsy, slurred speech, and generalized weakness. The patients were treated with botulism antitoxin released by the California Department of Public Health (CDPH). The sources of the black tar heroin remain unknown and additional cases may occur. Five (5) botulism cases associated with black tar heroin injection occurred in San Diego County in late 2010.
Supportive care is the mainstay of treatment for wound botulism. To reduce the incidence of respiratory failure, the botulism antitoxin should be administered as early as possible, prior to wound debridement, and ideally within 12 hours of presentation. Antibiotics are also recommended (e.g., penicillin or metronidazole). More information about botulism and guidance for clinicians are available on the Centers for Disease Control and Prevention (CDC) botulism website.
San Diego County healthcare providers are requested to do the following:
- Be alert for suspect cases of wound botulism, especially in injection drug users.
- Immediately report suspect cases to the Epidemiology Program at (619)-692-8499 (Monday–Friday, 8:00am–5:00pm) or after hours at (858) 565-5255. Epidemiology Program staff can facilitate release of botulism antitoxin from CDPH.
- Conduct a thorough search for wounds when examining patients with a history of injection drug use.
- Consider prompt neurology, infectious disease, and surgical consultation as indicated.
- Obtain pre-antitoxin serum for toxin assays (in serum separator tubes). Click here for instructions for specimen collection and submission.
- Warn patients who inject drugs, particularly black tar heroin, about the risk of wound botulism and other potentially life-threatening infections and conditions associated with drug use. Cooking or cleaning the drug will not prevent botulism infection. Risk reduction strategies for patients are available here.
- Educate patients about the symptoms of wound botulism and advise them to go to the nearest emergency department should symptoms develop. Fact sheets are available in English, Spanish, and Chinese.
- Due to their higher risk for tetanus, patients who inject drugs should receive tetanus vaccine every five years.
A useful checklist developed by CDPH is available to healthcare providers relating to the diagnosis and management of wound botulism. Click here for a modified version of the checklist. Providers are strongly encouraged to use this checklist when managing patients suspected to have wound botulism.
CAHAN San Diego
County of San Diego, Health & Human Services Agency
Epidemiology and Immunization Services Branch
Phone: (619) 692-8499 • Fax: (858) 715-6458
Urgent Phone for PM / Weekends / Holidays: (858) 565-5255
Email: cahan@sdcounty.ca.gov
Secure Website: http://cahan.ca.gov
Public-Access Website: http://www.cahansandiego.com
CAHAN San Diego Alerts are intended for the use of public health, medical and laboratory professionals in San Diego County. This alert has been approved for reproduction and distribution to interested professionals. An online CAHAN San Diego application is available at http://www.cahansandiego.com for appropriate and interested individuals.