Teaching Points:

• Wound Botulism is due to a bacterial toxin that disturbs the transmission of acetylcholine to bind to nicotinic/muscarinic receptors.
• Majority of patients get botulism primary from foodborne illnesses, only a small percentage get botulism from wounds.
• Wound botulism can also be commonly seen in patients who use black tar heroin (skin poppers). Injection of material into subcutaneous and/or muscle tissue provides the ideal environment for anaerobic bacteria – Clostridium botulinum.
• Clostridium botulinim can produce 8 different strains of toxin – A – H
• Clinical Manifestations
  • Patients present initially with bulbar symptoms and occasionally ocular abnormalities (diplopia, disconjugate eye movement, pupillary defects)
  • Also present as a symmetric descending paralysis complicated respiratory drive
  • Check history for evidence of skin popping
  • Wound botulism is more likely to cause fever and leukocytosis compared to other forms of botulism.
  • Patients with foodborne botulism typically present first with GI symptoms prior to onset of neurologic abnormalities
• Diagnosis
  • Important to suspect this in a patient with evolving neurologic deficits
  • Important to obtain wound culture for those who perform skin popping.
  • Diagnosis made by injecting mice and observing clinical manifestation. Then you reinject a second mouse with patient’s serum and antitoxin. If second mouse lives, that’s the diagnosis.
• Treatment
  • Supportive care including close airway monitoring (intubation if needed)
  • Botulinum heptavalent antitoxin
  • Monitor clinical status – typically a prolonged course of recovery as new axons grow from neurons to develop new neuromuscular junctions for function.
• Differential Diagnosis
  • Myasthenia Gravis
    • fluctuating weakness worse with repetition/activity
    • Initially involves the bulbar muscles, ptosis
    • Classically associated with thymomas (~80%)
  • Lambert Eaton Syndrome
    • No bulbar involvement. Proximal muscle involvement, ptosis.
    • Improves with repetition
    • Classically associated with small cell lung CA
  • Guillan Barre Syndrome
    • ascending paralysis, sensation intact although patients complain of vague symptoms.
    • Preceding viral URI or GI symptoms
    • Presence of autonomic symptoms such as hyper/hypotension, fluctuating temperatures, urinary incontinence/retention, brady/tachycardia, etc
  • Tick paralysis
    • Very similar presentation to GBS except no autonomic symptoms
    • Often times a tick can be found on the patient’s skin.