Thanks to Alison for presenting the case of a middle aged man who presented with acute onset of ptosis, dysphagia, and dysarthria, with an evolving exam found to have botulism secondary to IV injection of black tar heroin.

Clinical Pearls

• Botulism is extremely rare! Only 110 cases were reported last year in the US with 70-75% of them being related to infant botulism, 20-25% foodborne, and 5-10% wound botulism.  The latter category has been on the rise especially in California.
• Most common form of botulism is infant botulism
• Botulism presents with bulbar symptoms; progressive, descending paralysis; absent reflexes; and autonomic dysfunction
• Management involves the following
  • Notify the Department of Public Health ASAP if botulism is on your ddx
  • Obtain wound/blood cultures (special tube to be sent to DPH)
  • Administer antitoxin EARLY (do NOT wait for culture confirmation)

For more information, check this prior post on our blog.