On Sunday November 7^th, Public Health – Seattle & King County was notified of a suspect case of wound botulism in an injecting user of black tar heroin.  Preliminary laboratory results indicate botulism and the patient has clinical signs and symptoms consistent with wound botulism.   Botulism is most commonly transmitted by ingestion of preformed toxin from food products or inoculation of C. botulinum spores following trauma, or intramuscular injection or snorting of drugs, typically black tar heroin, contaminated with C. botulinum spores.  Healthcare providers in King County should maintain vigilance for wound botulism in users of illicit drugs.

Botulism should be suspected in patients with cranial nerve dysfunction manifested as difficulty seeing, speaking and/or swallowing, followed by symmetric descending weakness and paralysis. Clinical hallmarks include ptosis, blurred vision and the "4 Ds': diplopia, dysarthria, dysphonia, and dysphagia. A history of injecting or inhaling black tar heroin should be sought and a thorough physical exam for evidence of cellulitis and abscesses and examination of the paranasal sinuses should be performed. CSF protein is normal in botulism; EMG may help differentiate causes of paralysis.

Initiation of treatment with antitoxin should be based on the clinical diagnosis and should not await laboratory confirmation. Early treatment with botulinum antitoxin is important to prevent progression to respiratory failure, the most frequent cause of death. Wounds suspected of being contaminated with C. botulinum should be widely debrided and irrigated, ideally after the administration of botulinal antitoxin. Anaerobic cultures should be obtained. Mechanical ventilation is the main supportive therapy for severe cases of botulism.

Suspected cases of botulism should be reported to Public Health immediately at 206-296-4774 to facilitate: 1) laboratory confirmation of the diagnosis (submit serum and tissue specimens for suspected wound botulism), 2) assistance in obtaining antitoxin from the Centers for Disease Control and Prevention, and 3) prompt investigation and removal of likely sources of transmission and identification of other persons at risk for illness.

Whenever possible, please obtain the following information from suspected botulism cases:

• Patient's address including city; telephone or contact information; names and contact information for of family and/or friends who can be interviewed.
• Name and contact information for other persons with similar symptoms.
• Drugs injection history including drugs injected, preparation (e.g., black tar), dates used in past two weeks; route administered (IV, IM, SC or "skin popping", inhaled); names and contact information for individuals with whom patient shared drugs or works in past 2 weeks.
• Food history for the past 7 days including: group meals or gatherings, home canned foods, other canned foods, vacuum packed foods, seafood, potpies, smoked meats, fish, sausages, honey.
• History of gut resection, recent antibiotics, other clinical history to suggest altered gut flora.

For more information see www.cdc.gov/ncidod/dbmd/diseaseinfo/botulism_g.htm