Bacillus cereus cellulitis from contaminated heroin

Abstract

Concern exists over recent unexplained deaths among intravenous drug users. This report describes a patient with crepitant cellulitis who was admitted complaining of severe pain in the right forearm. Ultrasonography demonstrated gas in the tissues and he was referred for early surgical debridement of the arm. He was treated with intravenous benzyl penicillin, gentamicin and metronidazole and made a full recovery. Aspirate samples grew Bacillus cereus, morphologically similar to the isolate obtained from a sample of the patient's own heroin. Antibiogram and API 50CHB pro®les were also similar. Further typing included`H'¯agellar serotyping, which found both blood and heroin strains to be non-typable, and ampli®ed fragment polymorphism analysis, which showed that the strains were indistinguishable. Genotyping of two selected genes from B. cereus con®rmed almost certain identity between the two strains. This case illustrates the potential virulence of B. cereus when inoculated into tissues, and to our knowledge, is the ®rst report to demonstrate a conclusive microbiological link between contaminated heroin and serious sepsis in a drug user due to B. cereus.

An investigation into the microflora of heroin

“…Because only very low levels of all bacteria were detected, the possibility that C. novyi and C. botulinum were both present but were below the detection limit of the method used here cannot be excluded. However, these studies did identify contamination of heroin by B. cereus, C. perfringens and S. aureus, all of which were isolated from clinical samples collected from infected IDUs during the 2000 outbreak [16,17]. B. cereus endocarditis and ophthalmitis from contaminated heroin or injection paraphernalia have been reported elsewhere [23,36].…”

“…One of the samples was obtained from an IDU and indistinguishable isolates of B. cereus were obtained from both the aspirate from an injection site wound and from a heroin sample used by the patient [17,34]. A summary of the results from these 16 samples is given in Table 4.…”

“…IDUs in 2000, 16 samples of heroin were collected in England and Scotland (two of which were not identified as part of the outbreak) and examined by various techniques [16,17,34,35]. One of the samples was obtained from an IDU and indistinguishable isolates of B. cereus were obtained from both the aspirate from an injection site wound and from a heroin sample used by the patient [17,34].…”

“…During the course of the investigations among IDUs during 2000, B. cereus, C. botulinum and C. perfringens were isolated from either heroin or drug injection equipment ( [17] PHLS unpublished data). Because of the possibility that heroin was the source of infection, especially with C. novyi, investigations were established to develop methods for the analysis of the microbial flora of heroin.…”

“…During the intensive investigation more than 108 cases with at least 43 deaths were recognised between April and Aug. 2000 [10][11][12][13]. C. novyi type A was the likely cause of the more serious illnesses [12,[14][15][16], although other endospore-forming bacteria were also associated with some cases including C. perfringens [16] and B. cereus [17]. Cases of wound botulism were also reported in IDUs during 2000 and these represent the first recognition of this condition in the UK [18][19][20][21].…”