Margaret A.WinkerMD, Senior EditorIndividualAuthorPhil B.FontanarosaMD, Senior EditorIndividualAuthor
To the Editor.—The 1994-1996 outbreak of WB in California has been linked to skin-popping BTH.1 We consulted with 7 of these patients, 4 of whom had presentations with unilateral cranial nerve findings, considered atypical of classic WB.
A 34-year-old man presented after choking while trying to take his crushed methadone in apple sauce and realizing he could no longer swallow pills. He had 3 days of weakness of his right eye, blurred vision, and difficulty speaking and swallowing. On examination, he had bilateral eyelid ptosis, with lateral rectus muscle weakness of his left eye greater than his right and decreased strength in his right arm.
Horowitz BZ, Swensen E, Marquardt K. Wound Botulism Associated With Black Tar Heroin. JAMA. 1998;280(17):1479–1480. doi:10-1001/pubs.JAMA-ISSN-0098-7484-280-17-jbk1104
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