Arm abscesses caused by Clostridium botulinum

Abstract

Wound botulism is an uncommon disorder that continues to be rarely reported in the United States. A 34-year-old intravenous heroin user was admitted to the Loma Linda, Calif., Veterans Administration hospital with multiple abscesses on his forearms. His clinical course was compatible with botulism, and his culture and serum were positive for Clostridium botulinum toxin type A. Early culture and/or serum identification can lead to prompt diagnosis, treatment, and improvement in the morbidity and mortality rates of this disease. Wound botulism, although rare, is now being considered more often as a disease entity (12). This is due, in part, to the expanded spectrum of botulism and the awareness of physicians and laboratorians of the presence of Clostridium botulinum and its toxins in wound botulism and infant botulism. In recent years, C. botulinum has been identified as an unusual complication of wound infections in chronic intravenous drug users (7). Here we present the salient features and microbiologic studies of such a case. Case report. A 34-year-old male intravenous heroin user was brought to the emergency department of our hospital complaining of shortness of breath and multiple abscesses on both forearms. He had no known history of pulmonary disease. His last heroin use was on the day prior to admission. The patient was recently treated with methadone in a county clinic. After admission, the patient developed apneic respiratory arrest and was intubated and transferred to the medical intensive care unit. At that time, he appeared somewhat dehydrated and drowsy but was easily aroused and oriented. He complained of dryness of the mouth, tongue, and throat which was unrelieved by drinking fluids. Additional symptoms included bilateral facial weakness, ptosis, double vision, and difficulty in swallowing and speech articulation. Three days later, the soreness in his throat increased and pronounced weakness of the neck flexors occurred. He also developed weakness of the extremities (especially the upper ones), with progressive symmetric descending paralysis. The patient had no nausea, vomiting, or diarrhea and had not eaten any home-canned foods. He had shared food with others, none of whom had become ill. The admission examination showed the patient's axillary temperature as 99.2°F (approximately 37°C). The chest X-ray was negative. Initial laboratory studies showed a leukocyte count of 13,000/mm3, hemoglobin of 13.5 g/dl, a hematocrit of 41%, an arterial blood gas pH of 7.45, a P02 of 65 mm, a pCO2 of 38 mm, and an HCO3 of 26 mmol/liter, i.e., 92% of saturation. Anaerobic cultures of the forearm ab

Pathogenicity and virulence of Clostridium botulinum

“…Due to the nature of infection, the presentation of clinical symptoms typically takes longer than those of other clinical forms of botulism, typically presenting between 4 and 14 days [ 112 ]. Historically, cases were comparatively rare and usually implicated with trauma events, however the increasing prevalence of injecting drug-users led to a dramatic increase in the number of wound botulism cases [ 113–115 ]. In particular, an epidemic of cases in the state of California in the United States arose due to increased usage of black tar heroin through the late 1980s into 1990s [ 116 , 117 ].…”