"A 43-year-old IV heroin abuser presented to four separate medical facilities over a 2-week period. He complained of skin abscesses and progressive weakness. He was treated with oral dicloxacillin at the first facility, was discharged without treatment at the second, and received naloxone at the third. He then presented to our emergency department. His complaints included progressive dysphagia, dysarthria, diplopia, and extremity weakness. He denied pain and other symptoms. He was taking 30 mg methadone daily and 500 mg dicloxacillin four times daily as prescribed at his methadone clinic. His medical history was significant for years of IV drug abuse with several previous forearm abscesses. The patient's physical examination revealed blood pressure, 152/80 mg Hg; pulse, 120; respirations, 28; and tympanic temperature, 35.3 degrees C. He was dyspneic and unable to sit without assistance. Dysarthria was pronounced, and his gag reflex was minimal. Chest excursion and air movement were poor. Skin abscesses were noted in his right antecubital fossa and left volar forearm. Neurologic examination revealed the patient to be alert and oriented. He had paresis of cranial nerves III through VII and IX through XII. Motor function was very weak proximally, with only trace movement of the shoulder, trunk, and pelvic musculature. He was able to move his distal extremities against slight resistance. Sensory function was normal. Coordination was impaired due to weakness. [...] A presumptive diagnosis of wound botulism was made in the ED. Therapy included 0.5 mL tetanus toxoid IM, 250 units tetanus immune globulin IM, and 4 million units aqueous penicillin G IV. The Centers for Disease Control and Prevention and the California Department of Health Services were called in to obtain Trivalent (A, B, E) Botulinum Antitoxin (Connaught Laboratories Limited, Willowdale, Ontario, Canada). The patient was taken from the ED to the operating room, where he was intubated and his abscesses were debrided surgically. The botuinum antitoxin was flown in from the San Francisco branch of the Centers for Disease Control and Prevention and arrived after surgery. The patient was given an initial dose of one vial IV and one vial IM. Each vial contains 21,500 IU (type A, 7,500; type B, 5,500; type E, 8,500). This dose was repeated the next day for worsening ptosis and weakness of extraocular muscles. The patient's signs and symptoms stabilized after the second dose. Wound cultures subsequently grew Clostridium botulinum, and serum analysis revealed type A botulinum toxin. The patient was hospitalized 111 days with 76 days of ventilator support. He was discharged home with a tracheostomy and gastrostomy. He made a full recovery."2
"To our knowledge, we report the first case of wound botulism associated with a tooth abscess. [...] A 5-year-old boy developed pain in a left lower [...] molar in August 1991. His dentist identified a cavity and filled it. Pain recurred in mid-October, and examination revealed that the cavitary process with secondary infection had extended in the tooth, which was treated with debridement. A temporary filling was placed. Two days after this procedure, the pain continued, and the dentist prescribed erythromycin. Swelling persisted for some time, and a pediatrician prescribed cephalexin, which resulted in some abatement in the swelling. In mid-November, the dentist removed the filling and drained an abscess. The patient's jaw remained swollen, and the parents brought him to the hospital the evening of the drainage procedure because of respiratory difficulty, fever, and weakness. There was no history of consumption of home-canned foods, and no one else in the family was ill. The family of the patient reported that when he plays in the garden he frequently puts his dirty hands in his mouth. The patient was admitted to the intensive care unit and treated with iv cefotaxime. On examination, he was afebrile, and neurological examination showed ophthalmoplegia, a diminished gag reflex, severe weakness of the sternocleidomastoid muscles, and mild weakness of peripheral muscles. [...] The patient received mechanical ventilation, and the affected tooth was removed 48 hours after admission. The bed of the tooth did not appear affected. Aerobic and anaerobic cultures of material swabbed at the time of extraction were negative. The patient received 6 mL of trivalent (types A, B, and E) botulinal equine antitoxin provided by the CDC. He received iv cefotaxime for 10 days and po clindamycin for 7 days. He remained intubated for 15 days. After extubation, the patient had dysphonia and dysphagia that resolved over several months. The patient still had mild left facial weakness 7 months after his infection was diagnosed."29
"On September 23 [1995], a 44-year-old male user of black tar heroin developed an abscess on his right arm, which was treated unsuccessfully with cephelexin and ciprofloxacin; on September 29, the abscess was incised and drained. On October 1, he was examined at a local emergency department (ED) because of slurred speech and was released. On October 3, he sought care in the ED of a community hospital in Yolo County because of difficulty swallowing, which progressed to slurred speech, blurred vision, neck and arm weakness, and shortness of breath. Findings on physical examination included ophthalmoplegia; ptosis; and weakness of his facial, sternocleidomastoid, and deltoid muscles. Examination of a sample of his cerebrospinal fluid detected a marginally elevated protein level (50 mg/dL). A "Tensilon® test" (intravenous administration of edrophonium bromide to improve strength) was negative, and electromyography was not performed. Despite treatment with intravenous gamma globulin for suspected Guillain-Barré syndrome, weakness progressed, and on October 4, he required mechanical ventilation. On October 5, the diagnosis of wound botulism was considered, and CDHS was consulted. Two vials of botulinal antitoxin were released by CDHS and administered to the patient; in addition, treatment with 12 million units of penicillin daily was initiated. A serum specimen obtained from the patient on October 4 was positive for Type A botulinal toxin by mouse bioassay. No tissue from the abscess could be obtained for culture. The patient was discharged on November 21."31
"On September 25 [1995], a 30-year-old pregnant woman who reported last skin popping black tar heroin on September 24 sought care at an ED in Ventura County because of a sore throat and the sensation of "heavy eyelids." An upper respiratory tract infection was diagnosed, and she was released. On September 27, she developed difficulty swallowing and speaking and was admitted to a community hospital for evaluation. During the 12 hours following admission, she developed ophthalmoplegia and profound, symmetric, proximal paralysis of arms and legs, affecting her arms more than her legs; she subsequently required mechanical ventilation. A Tensilon® test was negative. Electromyography with repetitive motor-nerve stimulation at 10 Hz increased the muscle action potential by 17%. Lumbar puncture could not be performed. On September 29, she underwent wide excision of multiple abscesses on her left leg. Botulism was suspected; CDHS was consulted and released two vials of antitoxin for administration to the patient. Treatment with high-dose penicillin was initiated. Tissue and serum specimens obtained from the patient were positive for type A botulinal toxin by mouse bioassay, and histochemical staining of an excised abscess indicated the presence of spores and vegetative cells consistent with Clostridium botulinum. Culture of tissue from the wound yielded C. botulinum type A. On November 21, the patient was discharged from the hospital; her baby, who was delivered by cesarean section at 34 weeks on November 11, remained in intensive care on December 7."31