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
botulinum 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 health-care 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.
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.
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
spore-laden 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.
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.
Wound Botulism Among Black Tar Heroin Users— Washington, 2003. JAMA. 2003;290(14):1848. doi:10.1001/jama.290.14.1848