This report describes rapid geographical clustering of wound botulism with severe respiratory complications in IDUs after "skin popping," which has not previously been reported either in Germany or any other European country. Based on these observations and those in other European countries, we conclude that there is a trend towards "skin popping," suggesting a change in injection practices in IDUs. Secondly, we conclude that the total number of cases with wound botulism is likely to increase because "skin popping" is the main risk factor.

Objective: To report a case of multiple sclerosis (MS) with delirium as the first presentation. Clinical Presentation and Intervention: A 34-year-old female was referred to our department with an acute onset of drowsiness, withdrawal from routine activities and aggression, followed by neurologic deficits after a couple of days. Clinical and radiographic examinations were performed, leading to the initial diagnosis of MS. A vast range of differential diagnoses was excluded to confirm the diagnosis of MS. Conclusion: Neurological examination and appropriate imaging enabled the diagnosis of MS with delirium in this patient followed by the appropriate treatment.

The incidence of wound botulism is increasing dramatically among intravenous drug users. Efficient intensive care and early treatment with antitoxin is essential to avoid lethal courses. The clinical picture of botulism is of descending, symmetric, flaccid paralysis. Early symptoms include cranial nerve palsies resulting in blurred vision and diplopia, difficulty in focusing, ptosis, facial weakness, dysphagia, dysphonia, and dysarthria. Because patients presenting with dysarthria and dysphagia will often be seen by an ear, nose and throat specialist initially, this rare but upcoming neurologic disease must be considered in the differential diagnoses.