18 Jun 2021

3/31/21: Wound Botulism

PGY2 Salvador Rosales presented a case of 61 y/o male with no significant PMH who presents with dizziness that started >12 hours ago.  When at work, he had acute onset of dizziness, blurry vision, and difficulty walking that has been constant and he feels worsening.  He also notes that his voice is starting to sound weaker and that he is having difficulty swallowing.  He denies any neck pain, throat pain and neck stiffness but does report his L lateral neck feeling “numb and heavy”.

ROS: per HPI

Denies any past medical, surgical or family history.  No home medications or allergies.

Social History: Works at a recycling company.  History of IVDU with heroine.  Denies any alcohol use.

Vitals: T 37.0, HR 65, RR 19, BP 100/69, O2 sat 97% on RA

Physical Exam significant for unsteady and unable to transfer self from wheelchair to gurney on his own.  +truncal ataxia.  Cardiac, pulm and abdominal exam normal.  +large, tense, slightly erythematous abscesses on b/l UE (near deltoid).  A&Ox4, +b/l ptosis, slight raspy voice, 4/5 strength throughout upper and lower extremities, finger to nose dysmetria.

CBC: WBC 7.5> Hb 11.4/Hct 34.3 <Plt 284 (MCV 77.5, RDW 15.6%)

CMP:

Na 140/K 4.3/Cl 101/HCO3 33/BUN 13/Cr 0.55<Glucose 100

ALP 79>T.protein 6.8/Albumin 3.3/AST 56/ALT 46/Tbili 0.3/Dbili 0.2

Ca 9.1, Mg 2.0, Phos 3.4

Coags: PT 14.1, INR 1.10

Infectious workup negative for BCx, UA, UCx ,HIV, and RPR.  Hep C was positive with elevated viral load.

Wound Cx positive for staph hominis, diptheroids and clostridum perfringens.

LP performed with normal rare nucleated and lymphocytes, normal glucose and protein levels, no growth in culture and biofire panel negative.

Given concern for myasthenia gravis, Anti-AchR and Anti-MuSK sent and were negative.

MRI Brain: no evidence of acute infarct or acute bleed.

CT of bilateral upper extremities with contrast: numerous rim enhancing fluid collections along the L and R pectoralis major muscle, the deep fascial planes of the volar aspects of the arms.

Botulinum Toxin: Positive (resulted on hospital day 8)

Treatment: I&D performed with wound cultures sent.  Given concern for wound botulism, Neurology and Toxicology consulted.  Patient with increased respiratory secretions and excessive phlegm and was intubated for airway protection.  He was given botulinum anti-toxin x1 and transferred to MICU.  Patient was treated with PCN G IV and clindamycin given the wound culture results.  Further I&D done with Ortho in the OR.  Patient recovered by hospital day 14 to be discharged.

Teaching points:

  1. Wound botulism is associated with injection drug use, particularly “black tar” heroin.
  2. Presents similar to foodborne botulism but without GI prodrome and with longer incubation. Sx: descending paralysis starting with the eyes and moving down.  Does not effect CNS given the toxins are too large to cross the BBB.
  3. Treatment: antitoxin (does not reverse symptoms, just stops the toxin from causing more damage), antibiotics and wound debridement.

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.