Descending paralysis resulting from occult wound botulism

Area of Science:

• Neurology
• Toxicology
• Infectious Diseases

Background:

• Botulism is a rare paralytic illness caused by toxins from Clostridium botulinum bacteria.
• Wound botulism, often associated with injection drug use, can present with symptoms mimicking other neuromuscular disorders.
• Accurate diagnosis is crucial for appropriate treatment and patient outcomes.

Observation:

• A 30-year-old male with a history of drug abuse presented with ophthalmoplegia, bulbar paralysis, and limb weakness.
• Initial symptoms were responsive to edrophonium, suggesting myasthenia gravis.
• Electrophysiological studies revealed findings consistent with botulism, specifically type B.

Findings:

• The source of botulism type B was identified as a subcutaneous cyst from cocaine infiltration.
• Repetitive nerve stimulation at 10 Hz showed potentiation of evoked muscle action potentials.
• The patient's condition improved with pyridostigmine bromide and plasmapheresis.

Implications:

• Wound botulism may be underdiagnosed due to its similarity to inflammatory neuropathies and myasthenia gravis.
• Neuromuscular transmission studies are essential for diagnosing acute craniosomatic paralysis.
• This case highlights the importance of considering botulism in patients with unexplained paralysis, especially those with a history of substance abuse.