Wound Botulism From Injected Methamphetamine: A Case Doctors First Took for a Stroke

On May 15, 2020, a 41-year-old man came to a New Jersey emergency department with two days of blurred and double vision, drooping eyelids and difficulty swallowing. His brain scans were normal, and he was sent home with a diagnosis of double vision. The next day, worse — slurred speech, facial weakness — he went to a second emergency department and was admitted as a possible stroke. The real cause was botulism, and it came from a syringe.

The clue

He had used methamphetamine for about 20 years, always by inhaling it, he said. But after two weeks without it, he had injected methamphetamine mixed with water from a bottle that had been open at home for an unknown time, 24–48 hours before his symptoms began. Recent injection drug use raised suspicion of botulism, a paralytic illness caused by botulinum neurotoxin. As far as he knew, no one else who injected the same batch had a reaction.

• Examination found inflamed veins and hardened spots on the skin, but no abscess or open wound.
• The New Jersey Department of Health was notified at once, as state rules require, and after consultation with CDC, botulinum antitoxin from the CDC quarantine station in New York was given within 24 hours of admission.
• He never needed a ventilator. His double vision, drooping eyelids, swallowing difficulty and facial weakness gradually improved, and he went home five days after the antitoxin, with mild blurred vision and referrals for rehabilitation and follow-up.
• Blood taken before treatment tested positive for botulinum neurotoxin type B.

Why the case matters

Injection drug use is the leading cause of wound botulism in the United States. Most cases occur in the West and Southwest and may be linked to the supply of black tar heroin, and most involve toxin type A: in 2018, 47 of 51 laboratory-confirmed wound botulism cases were type A, and every patient reported injecting drugs.

This case was methamphetamine and type B, and it teaches three things:

1. Anyone who injects drugs is at risk of wound botulism, not only people who inject black tar heroin — and the people who inject, and the clinicians who treat them, should know the signs.
2. It can look like something else. Drooping eyelids and altered speech can be mistaken for mental changes from methamphetamine use, so a thorough neurologic exam matters.
3. No visible wound is needed. Mild wounds can harbor the Clostridia bacteria that make the toxin, so wound botulism should be considered in anyone with a history of injection drug use, even without an abscess.

Early recognition and treatment reduce illness and death.

Sources

Based on "Notes from the Field: Botulism Type B After Intravenous Methamphetamine Use — New Jersey, 2020," by Michelle A. Waltenburg and colleagues (CDC, Morristown Medical Center, New Jersey Department of Health), Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention; a work of the United States government in the public domain.