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Wound botulism has been reported among injection drug users; however, diagnosis can be challenging, and initial misdiagnosis can delay appropriate treatment. Objective: To increase the clinical awareness of wound botulism and its symptoms to reduce misdiagnosis and improper treatment. Case study: A 43-year-old Caucasian male with a history of daily heroin use presented with acute onset descending weakness. Neurological examination showed bilateral ptosis, facial diplegia, and proximal weakness with diffuse hyporeflexia. Electrodiagnostic study demonstrated normal median and spinal accessory nerve compound muscle action potential amplitudes without an incremental response after a 10-second exercise. Median nerve repetitive nerve stimulation at 2 Hz revealed a decremental response at rest. Wound botulism was suspected despite lack of typical electrodiagnostic findings. The patient received botulism antitoxin, with partial improvement of his neurological symptoms. Mouse bioassay (MBA) with serum sample from the patient was negative; however, botulinum toxin type A was detected in serum via matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. Conclusion: Despite the absence of classic electrodiagnostic findings of a presynaptic disorder and a negative MBA, clinicians should remain aware of wound botulism in particularly at-risk patients.

Wound Botulism in a Drug User—A Case Report and a Review of Botulism