A Case Report of Wound Botulism - Rare Disease on the Rise with the Opioid Crisis.

Wound botulism is a rare, underrecognized life-threatening illness caused by a toxin produced by Clostridium botulinum, a spore-forming anaerobic bacterium. Approximately 20 cases are reported in the United States each year, mostly from California. Most wound botulism cases occur in drug injectors, particularly among those using black tar heroin. The initial presentation of botulism may overlap with other diagnoses, including opioid intoxication and pre-existing neurological disease, making accurate diagnosis difficult. A healthy 40-year-old patient with a history of injecting black tar heroin presented to an emergency department complaining of generalized weakness and throat discomfort. He was given antibiotics and was sent home. The next day, the patient presented to another emergency department with additional complaints of slurred speech and blurring of vision. He was admitted for a possible cerebrovascular injury. In the absence of positive findings from laboratory or imaging studies, botulism was considered. The patient decompensated and was intubated. Botulism antitoxin was given, and the patient eventually recovered. Prompt decision-making based on clinical suspicion and an informed presumptive diagnosis, administration of botulism antitoxin, and aggressive provision of supportive care can arrest the progression of paralysis and be life-saving. With the rise of opioid use in the United States, leading to a reversion to heroin as a cheaper form of opioids, cases of wound botulism may be on the rise. Clinician attentiveness to obtaining substance history and being aware of botulism presentation may lead to life-saving treatments for these patients. ©Copyright 2021 by University Health Partners of Hawai‘i (UHP Hawai‘i).