Wound Botulism Caused by Botulinum Neurotoxin Type A in a Chronic Parenteral Drug Abuser

Botulism is an acute paralytic disease caused by botulinum neurotoxin (BoNT)-mediated inhibition of neurosignaling at the neuromuscular junction. BoNTs are produced by gram positive, anaerobic, spore-forming bacteria from the genus Clostridium,most commonly Clostridium botulinum. Over the last decade, a previously uncommon form of botulism, wound botulism, has increased in prevalence possibly due to the rise in parenteral drug abuse. A 53-year-old patient with a history of drug abuse presents to a rural emergency department with rapidly progressing lower extremity weakness over the past few days. He reports a recent heroin injection into right buttock and diffuse skin-popping scarring was observed throughout. The patient was treated with heptavalent botulinum antitoxin obtained from the Center for Disease Control and Prevention (CDC). A right thigh abscess culture was positive for Clostridium tertium, a left hip abscess culture was positive for methicillin-susceptible Staphylococcus aureus (MSSA), and blood culture confirmed multi-microbial bacteremia caused by Staphylococcus epidermidis and Streptococcus mitis. Serum analysis was positive for BoNT type A from a suspected concurrent Clostridium botulinum infection as C. tertium is not known to produce BoNT type A. This case report highlights the importance of early antitoxin treatment for patients with suspected wound botulism.