Infectious Disease Reports 2018; volume 10:7654 Wound botulism caused by of wound botulism is commonly associated Clostridium subterminale after with injection drug users but has also been Correspondence: Aimee Mishler, Department described in traumatic injuries with of Pharmacy, Maricopa Medical Center, 2601 a heroin injection exposure to soil. East Roosevelt Street, Phoenix, AZ 85008, USA. Paris A. Cook,1 Aimee Mishler,1 Tel.: +1.602.344.5686 - Fax: +1.602.344.5565. E-mail: [email protected] Dan Quan,2 Ashley Parrish-Garcia2 1Department of Pharmacy; 2Department Case Report Key words: Botulism; wound botulism; anti- of Emergency Medicine, Maricopa A 33-year-old male had recently toxin; Clostridium; Clostridium subterminale. Integrated Health System, University of presented to another hospital in the area just Arizona, Phoenix, AZ, USA prior to admission at our hospital for Contributions: PC was the main author who weakness, fatigue and bilateral hip and leg completed the first draft of all sections, abscesses. At that time he elected to be excluding the abstract. AM was the author treated for cellulitis as an outpatient and who was the primary editor for the abstract, introduction, and discussion sections and was was prescribed cephalexin 250 mg by Abstract the author who completed the second draft, mouth four times daily and excluding the abstract, + coordinated all corre- Botulism is caused by toxin production sulfamethoxazole-trimethoprim 400-80 mg spondence between authors, was responsible from many species of Clostridium, most by mouth twice daily for ten days. He then for compiling each portion of the manuscript, commonly Clostridium botulinum as well presented to our hospital two days later with and was responsible for formatting and sub- as C. baratii and C. butyricum. a chief complaint of difficulty swallowing mitting the manuscript. DQ was the final edi- Development of wound botulism is and progressive weakness which he states tor for all portions. AP-G was the author who associated with injection drug users but has he had for one week. His past medical completed the abstract and was the primary also been described in traumatic injuries history included daily heroin use, editor for the case report section. with exposure to soil. A patient presented to administered by skin popping or injecting Conflicts of interest: the authors declare no the emergency department with a complaint the drug under the skin either intradermally conflictsonly of interests. of descending, progressive weakness. He or subcutaneously, and untreated hepatitis C.On presentation to our hospital, the recently reported skin popping with heroin Received for publication: 24 February 2018. injections. Heptavalent botulinum antitoxin patient was only able to open his eyelids 2- Revision received: 4 June 2018. was obtained from the [Center for Disease 3 mm wide and had difficulty keeping themuseAccepted for publication: 14 June 2018. Control and Prevention (CDC)]. On open, diplopia, difficulty swallowing and hospital day seven, the anaerobic wound pooling of secretions after 1-2 words, voice This work is licensed under a Creative cultures resulted with growth of changes, difficulty holding his head up and Commons Attribution-NonCommercial 4.0 Clostridium subterminale. proximal upper extremity weakness. International License (CC BY-NC 4.0). Strength in his upper extremities were 4/5. Initial vital signs included: blood pressure ©Copyright P. A. Cook et al., 2018 Licensee PAGEPress, Italy 136/80 mmHg; pulse rate 106 beats/min; Infectious Disease Reports 2018; 10:7654 Introduction respiratory rate 19 breaths/min; oral doi:10.4081/idr.2018.7654 temperature 36.5°C (97.7°F); and room air Botulism is an illness caused by toxin pulse oximetry 98%. Five deep cavity production from many species of the abscesses were incised and drained from the ® Clostridium genus of bacteria, most patient’s hips and thighs, and standard and antitoxin (A, B, C, D, E, F, G) –BAT commonly Clostridium botulinum, C. anaerobic wound cultures were collected. Equine was coordinated directly with the baratii, and C. butyricum. These bacteria After a few hours, the weakness became [Centers for Disease Control and are anaerobic, spore-forming, Gram- more pronounced in the patient’s neck and Prevention (CDC)]. The antitoxin arrived positive organisms found naturally in the extremities and breathing became very by freight air transport the next morning on soil. The different types of botulismNon-commercial include shallow. The decision was made to intubate hospital day two and was administered via foodborne botulism from improperly the patient in the emergency department for infusion approximately nineteen hours after canned or stored foods, infant botulism and airway protection and impending presentation to the emergency department. adult intestinal toxemia from ingestion of respiratory failure before transferring him Serum, stool and wound cultures were sent botulinum neurotoxin-producing species of to the [medical intensive care unit (ICU)]. A to the CDC for analysis. Wound cultures Clostridium in infants and adults, urine drug screen was positive for were also sent to the hospital’s lab for respectively, wound botulism, and amphetamines, opiates, and acetone. analysis. In addition, vancomycin and iatrogenic botulism as a result of cosmetic The constellation of symptoms seen in piperacillin-tazobactam, were started for or therapeutic botulinum toxin overdoses. the emergency department was suggestive broad antibiotic coverage including Wound botulism can occur when botulinum of botulism, with other differential possible [methicillin-resistant neurotoxin-producing species of diagnoses including Guillain-Barré Staphylococcus aureus (MRSA)]. Clostridium infect and germinate in wounds Syndrome and myasthenia gravis. He In the medical ICU, the patient’s and begin producing toxins. Wound reported not having eaten canned food that weakness plateaued and antibiotics were botulism presents most similarly to had been bulging and had not traveled deescalated to vancomycin and ampicillin- foodborne botulism with descending flaccid outside of the country recently. Therefore, sulbactam for continued coverage of his paralysis of facial, swallowing, and the suspicion was for possible wound complicated skin-soft tissue infection. After respiratory muscles, with the exception that botulism. The Maricopa County three days in the ICU (hospital day four), a it does not typically have accompanying Department of Public Health was contacted, tracheostomy was performed for the gastrointestinal symptoms.1-3 Development and receipt of heptavalent botulinum expected long recovery time and a PEG [page 42] [Infectious Disease Reports 2018; 10:7654] Case Report tube was inserted. The patient was then isolated from wounds. To our knowledge, patients who were enrolled in methadone transitioned to oral antibiotics, amoxicillin- this is the first case reporting a Clostridium programs in California and had never had clavulanate 875 mg by mouth twice daily subterminale positive wound culture with wound botulism. Both groups reported and sulfamethoxazole-trimethoprim 800- type A toxin identified in the serum sample. similar rates, 96% and 97% respectively, of 160 mg, two tablets by mouth twice daily C. subterminale is a species that is similar [black tar heroin (BTH)] use. Their results for two weeks. On hospital day seven, the to Group IV Clostridia and has been shown showed that a significantly higher anaerobic wound cultures analyzed by the to be able to produce typeG toxin, which is percentage of patients with wound botulism hospital’s lab resulted with growth of not responsible for human illness and to were injecting BTH by skin popping either Clostridium subterminale . On hospital day express the gene capable of producing type subcutaneously or intramuscularly than ten, results from the CDC serum analysis B toxin, however, has not been shown to their control counterparts (92% vs 44%, reported toxin A which was identified using actually produce this toxin.4-6 One study P<0.001).17 Other studies have continued to MALDI-TOF mass spectrometry, the which focused on Clostridia infections in look at wound botulism in injection drugs wound culture analyzed by the CDC did not post-traumatic wounds identified five cases users, especially those using BTH, and have report botulinum toxin, and the stool was where the growth of C. subterminale was found similar results.18 not analyzed. found associated with soil contamination.7 Early recognition of the signs and After a twelve-day hospital stay, the C. subterminale has been previously symptoms of botulism is important. Due to patient was discharged to a skilled nursing reported in immunocompromised patients neuroparalytic effects of the toxin produced facility. He continued to have bilateral undergoing chemotherapy, with three by Clostridium bacteria, there is a cluster of ptosis, difficulty swallowing and bacteremia cases reported.8-10 A separate symptoms typical of patients presenting generalized weakness. He continued to have case of bacteremia in an immunocompetent with botulism. The most classic signs are 4/5 bilateral deltoid muscle strength but 5/5 patient was found after an esophageal cranial nerve palsies and descending flaccid strength in all other major muscle groups. rupture.11 Additionally, there were two cases paralysis. The eyes are often reported as He had a tracheostomy placed on hospital reported C. subterminale in being affected first with signs of diplopia