Persons with wound botulism from heroin tend to be 20 to 60+ years old. Although more men than women inject heroin, women account for 30% to 50% of the persons with wound botulism.5,6 Most cases occur in the US.
There is no test to expediently diagnose wound botulism; serum, feces, and vomit can be cultured to determine C botulinum.4 Real-time polymerase chain reaction or mouse assay can detect the toxin, but results often are not rapid.4 Definitive diagnosis involves identifying the neurotoxin in serum or wound aspirate.5 The neurotoxin is not identified in all serum; an electromyogram can be helpful while waiting for serum toxin results. Misdiagnoses may occur because manifestations (ptosis, weakness, dysarthria) may mimic intoxication, which is a concern for persons with alcoholism. Many laboratory tests can be normal (complete blood cell count, chemistry, urinalysis, cerebrospinal fluid, liver function tests) unless an infection is present.5
The diagnosis often is made after thoroughly reviewing the person’s history and clinical manifestations. Because wound botulism generally is associated with skin popping and abscesses in those areas, skin should be thoroughly examined for injection sites and abscesses.2 The hallmark clinical features include cranial nerve palsies with descending paralysis.5 The most common symptoms are dysphagia/trouble swallowing, proximal muscle weakness of the upper and lower extremities, neck flexor muscle weakness, ophthalmoplegia, bilateral ptosis, dysarthria, double vision, blurred vision, and dry mouth.2,3,5 Sensations and mentation are not affected.5
Differential diagnoses include a variant of Guillain-Barre syndrome, autoimmune neuromuscular diseases (myasthenia gravis, Lambert-Eaton syndrome), organophosphate poisoning, paralytic shellfish poisoning, brain stem stroke, tick paralysis, hyperkalemic periodic paralysis, or poliomyelitis.3,5 Diagnoses can be confirmed by computerized tomography or magnetic resonance imaging of the head. Wound botulism may occur more than one time.
Yuan et al6 examined surveillance data in California from 1993 to 2006 that identified 17 persons who injected drugs with recurrent wound botulism. All injected heroin: 88% used black tar heroin and 76% reported subcutaneous injection.