Epidemic of Wound Botulism From Black Tar Heroin

MedicalResearch.com Interview with:
Guy Soo Hoo, MD
West Los Angeles VA Medical Center
Los Angeles, CA

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Wound botulism occurs as a result of infection by material contaminated with C. botulinum. While typically associated with trauma and crush injury, it is also an infection associated with injection drug users especially with “skin popping”. Black tar heroin is an especially common vehicle for the development of wound botulism. Black tar heroin is the predominant form of heroin used in the western United States and there has been an epidemic of wound botulism cases associated with black tar heroin users especially in California. In fact, the vast majority of wound botulism cases in California occurs in injection drug users, specifically those who inject the drug subcutaneously or intramuscularly.

The typical presentation in wound botulism in an acute neurologic illness with cranial nerve palsies, flaccid descending paralysis. Respiratory failure requiring mechanical ventilation may occur and may require an extended period of ventilator support for recovery. A high index of suspicion as well as general supportive care is needed for optimal treatment and recovery. Optimal treatment includes wound debridement, early administration of botulinum antitoxin and penicillin therapy. This case is unique in that the initial presentation was bilateral vocal cord paralysis and cranial nerve function was initially intact. The patient subsequently developed a flaccid paralysis that included cranial nerve palsies, functional quadriplegia and respiratory failure. He recovered to be discharged to a rehabilitation facility about six weeks after his initial presentation.

MedicalResearch.com: What should readers take away from your report?

Response: A high index of suspicion is needed to establish the diagnosis to allow for timely administration of therapy. The condition can be fatal if left untreated. Therapy as outlined has been demonstrated to decrease the duration of mechanical ventilation as well as duration of hospitalization.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Response: Investigation of common sources of C. botulinum contamination of black tar heroin will help explain the epidemiology of this rare infection in this group of patients. There is obviously contamination as the heroin is being prepared for sale and distribution.

MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.

Citation:

Bilateral Vocal Cord Paralysis and Respiratory Failure Secondary to Wound Botulism From Black Tar Heroin
Tyler Larsen, MD; Abigail Maller, MD; Jared Intaphan, MD; Jaime Betancourt, MD; Guy Soo Hoo, MD
Chest. 2016;150(4_S):1200A. doi:10.1016/j.chest.2016.08.1309

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