It looked like an overdose, and naloxone did nothing

Wound botulism is rare and specific: **botulinum toxin produced by bacteria
growing in a wound**, classically from **black tar heroin injected under the
skin** — a practice called skin popping.

San Diego County had averaged one case a year from 2001 to 2016. Between
26 September 2017 and 12 April 2018 it had nine (eight confirmed, one
probable). All nine were hospitalised. One died.

**All nine injected drugs. Seven specifically reported black tar heroin. Six
practised subcutaneous injection.** Eight were men; median age 40 (range
25–67).

Why it is missed

The symptoms are **muscle weakness, difficulty swallowing, blurred vision,
drooping eyelids, slurred speech, difficulty breathing, loss of facial
expression, descending paralysis.**

Read that list in an emergency department, about a person known to inject
heroin, and it looks like opioid intoxication.

**Symptoms were first attributed to drug intoxication for four patients; two
received the opioid overdose reversal medication naloxone without improvement
in symptoms.**

Naloxone not working is the tell, and it is a costly way to learn it. **Wound
botulism is likely under-recognised** because it is rare and because its
presentation overlaps with **opioid intoxication and overdose, Guillain-Barré
syndrome, the Miller Fisher variant, and myasthenia gravis** — four other
things that cause descending or ascending weakness.

What the delay costs

All nine were treated with heptavalent botulism antitoxin. The **median
interval from symptom onset to antitoxin was 6.5 days** (range 2.7–10.5).

Antitoxin neutralises toxin still circulating; it cannot reverse paralysis that
has already happened. **Prompt diagnosis, antitoxin and supportive care can
stop the progression of paralysis and be lifesaving** — and six and a half days
is a long time for paralysis to progress.

The antitoxin itself is not on a hospital shelf: the state authorised it and
**CDC quarantine stations in Los Angeles (eight) and San Francisco (one)
released it.** Every dose is a phone call to a public health authority, which
is another reason the diagnosis has to be considered before it can be
treated.

What the county did about it

After the first two cases, on 9 October 2017 — well before the outbreak
was over — the county **sent a health alert through the California Health Alert
Network** to Southern California providers, with the signs, symptoms and the
black tar heroin link.

That is the intervention: the bottleneck is a clinician's index of suspicion,
so the response is to raise it across a region before the next patient arrives.

**Increasing black tar heroin use during the opioid crisis might lead to
additional cases**, which makes the awareness durable rather than a one-off.

Source: Centers for Disease Control and Prevention, MMWR.