Wound Botulism Associated with Black Tar Heroin Use
Wound Botulism Associated with Black Tar Heroin Use
ABSTRACT & COMMENTARY
Source: Passaro DJ, et al. Wound botulism associated with black tar heroin among injecting drug users. JAMA 1998; 279:859-863.
Wound botulism (wb), a descending, flaccid, symmetric paralysis occurring after inoculation of a wound with the neurotoxin-producing spores of the obligate anaerobe Clostridium botulinum, generally occurs in the devitalized tissue of crush injuries. In 1988, the first case of WB in California was reported in an injection drug user (IDU), and, since then, 46 of 49 WB cases in California have been seen in IDUs-all of whom injecting black tar heroin (BTH), a black, thick form of heroin that is currently the most common form of heroin used in the western United States. Passaro and colleagues present a case control study of 26 IDUs who developed WB and 110 control IDUs recently enrolled in a methadone program, in an attempt to identify risk factors for the development of WB in IDUs.
Both groups were questioned extensively (34 specific questions in each group) about drug-related practices in the month prior to the development of WB or enrollment in the methadone program. Practices investigated included such things as route of drug administration, frequency and quantity used, method of needle and skin cleansing, water or solvent source, use of filters when drawing the heroin mixture into the syringe, and storage of drug.
Of the 35 laboratory-confirmed cases of WB during the study period, 28 patients could be located and 26 agreed to be interviewed. Nearly all patients required mechanical ventilation during their hospital stay, which generally was quite prolonged. Eighty-eight percent of cases were caused by botulinum toxin type A, and 12% were caused by type B. None of the patients were HIV positive. More than 95% of individuals in both groups injected BTH, with similar mean cumulative doses (P = 0.6). Compared to the control group, however, patients who developed WB were more likely to inject subcutaneously or intramuscularly (92% vs 44%; P < 0.001). Cleaning skin and/or injection paraphernalia and using new needles did not confer protection against the development of WB.
COMMENT BY FREDERIC H. KAUFFMAN, MD, FACEP
Passaro et al have demonstrated that extensive information about specific drug use practices can be obtained from IDUs. After nearly 15 years of emergency medicine practice in the inner city, I am still amazed by drug lore and the unusual practices carried out by IDUs. Passaro et al point out, for instance, that classic white heroin often contains adulterants such as strychnine, xylocaine, and dextrose, and that BTH may contain ground pepper, shoe polish, and soil. In addition, they logically assess that contamination of BTH with C. botulinum spores likely occurs during this "cutting" stage. Why the outbreak of WB has been limited predominantly to California remains unclear, but patterns of many infectious diseases and drug use practices commonly change, making WB an important complication in IDUs for all emergency physicians to consider.
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