Wound Botulism Cases Associated with Injection Drug Use

The Texas Department of State Health Services is reporting two confirmed and one suspected case of botulism associated with injection drug use since July 30, 2024.

Due to the nature of this illness, additional cases may occur. Clinicians should follow the recommendations below and report any suspected cases to their local health department or public health region immediately while the patient is still under their care.

Background

Wound botulism is a rare and potentially fatal paralytic illness that is caused when a wound is contaminated by Clostridium botulinum spores that germinate and produce neurotoxins inside the wound. Affected patients typically present with a sudden paralysis or weakness in the muscles of both sides of the face that can cause blurred or double vision, drooping eyelids, slurred speech, difficulty swallowing, or an impaired gag reflex. The initial symptoms are often followed by paralysis that progresses down the body to the trunk, arms, and legs.

A botulism outbreak in Northeast Texas has been identified including three cases in people with a recent history of injecting heroin. All three patients are associated with one another and experienced generalized weakness and acute respiratory failure requiring intubation. Public health officials do not know how many people could have been exposed, so additional cases may occur as the public health investigation continues to determine the source of infection.

Recommendations for Clinicians

All forms of botulism can be fatal and are medical emergencies. If botulism is suspected, consider starting treatment immediately before laboratory test confirmation.

Please see the CDC for additional guidance.

All providers should maintain a high index of suspicion for wound botulism in any patient presenting with the following signs and symptoms who also reports injection drug use. The classic symptoms of botulism include:

• Blurred or double vision
• Drooping eyelids
• Slurred speech
• Difficulty swallowing or speaking
• Dry mouth
• Muscle weakness
• Muscle paralysis, which may start with the face and progress down the body to the trunk, arms, and legs.

Be alert for possible cases of wound botulism in persons with compatible symptoms and recent history of injection drug use such as heroin, regardless of whether dermal wounds are visible. Initial presentations can be mild but quickly progress to severe illness. Refer suspected cases immediately to the nearest emergency department.

Consider neurology and infectious disease consultations to evaluate for botulism. Consider surgical consultations for thorough debridement of wounds and abscesses.

Any wound specimens should be sent for anaerobic culture. Serum testing for C. botulinum toxin can also be conducted by public health laboratories.

Suspected cases should be reported to your local health department or public health region.