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Wound Botulism - Causes, Symptoms, and Treatment

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Wound botulism is an infectious disease caused by a bacteria called Clostridium botulinum. Read the article to know more.

Medically reviewed by

Dr. Kaushal Bhavsar

Published At May 25, 2023
Reviewed AtJanuary 6, 2024

What Is Wound Botulism?

It is a non-communicable infection caused by a bacteria called Clostridium botulinum, the same bacteria that is used to produce Botox- a pharmaceutical product popularized for reducing wrinkles. This bacteria spreads through contaminated food, intestinal colonization (in infants), wound infection, and rarely through inhalation.

Wound botulism is caused by open wound exposure to bacterial spores (present in the environment) or by injecting drugs, especially Black Tar Heroin. It can also occur through traumatic injury involving contamination of soil. The spores of these bacteria, in the absence of oxygen, germinate and release botulinum neurotoxins (BoNTs) that can block nerve functions and lead to respiratory and muscular paralysis.

Treatment involves antitoxin therapy, surgical wound debridement, and antibiotics. Although it is a rare infection, death occurs in nearly 7 percent of the infected individuals.

What Causes Wound Botulism?

  • Although the infection is caused by toxin-producing bacteria, not all individuals who get exposed to the spores of these bacteria get infected. The disease was formerly related to traumatic injury and rarely to surgery, but nowadays affects mainly intravenous drug users (IVDU).

  • There are many opportunities to become contaminated with C. botulinum in the production and distribution process for Black Tar Heroin (BTH). The spores of Clostridium survive substances and temperatures that kill other bacteria.

  • The drug is “cut” with contaminated substances like wood pulp or dirt (both of which contain spores) by the drug dealers to sell more of it at a lesser expense to themselves. Spurs have also been found in drug Paraphernalia.

  • The BTH can be injected subcutaneously (known as skin popping) or intramuscularly, both of which require less accuracy than an IV (intravenous) injection. These methods also make the drug viable for a longer time than compared to venous access.

  • The subcutaneous route creates an ideal breeding ground for the spores to germinate and produce neurotoxins. The sharing of contaminated needles is also common among a selected group of drug users and will contribute to wound botulism.

  • In a few patients, the bacteria will form an abscess at the site of the injection of BTH, it will provide the necessary anaerobic environment for the spores to germinate and the organism to thrive.

  • The neurotoxins spread rapidly and systematically through the lymphatic and vascular systems causing symptoms like weakness, dysphagia, gait disturbance, and dyspnea.

What Are BoNTs?

  • The neurotoxins produced by C. botulinum are known as BoNTs (botulinum neurotoxins). There are seven forms of botulinum toxins- Types A - G; of these, only four types (type A, B, E, and F) are known to affect humans, and the other three types (type C, D, and G) affect birds, fish, and other animals.

  • Neurotoxins produced by C. botulinum are some of the most poisonous biological substances known; they interfere with neural transmission by blocking the release of acetylcholine (the principal neurotransmitter), causing muscle paralysis.

  • The affected nerves do not degenerate, but blockage of neurotransmitter release is irreversible. The function can be recovered by the sporting of new nerve terminals and the formation of new synaptic contacts; this usually takes time. The effects caused by type A BoNT are known to last for three months.

What Are the Symptoms of Wound Botulism?

Botulism is an infection that should be diagnosed based on symptoms alone because the symptoms start appearing within 12 hours to 36 hours (within a minimum and maximum range of four hours to eight days) after exposure, but the results typically take around four days (from the point of blood sample acquisition till the results). This delay will be lethal if the treatment is postponed till the completion of investigations. The symptoms that aid in diagnosis and treatment are-

  • Bilateral weakness.

  • Paralysis.

  • Reduced muscle tone without fever.

The above three are the classical medical triad of botulism. Botulism is a neuromuscular infection where the neurotoxin inhibits acetylcholine (a neurotransmitter) release and binds irreversibly to the presynaptic terminal (the distal end of a nerve that is specialized for the release of neurotransmitters). Other neurological symptoms are-

  • Mouth dryness.

  • Blurry vision.

  • Double vision.

  • Dysphagia (difficulty in swallowing).

  • Dysarthria (motor speech disorder).

  • Dysphonia (abnormal voice).

  • Flaccid paralysis involving the respiratory muscles leads to neuromuscular respiratory failure.

Patients with botulism do not demonstrate any sensory deficit; their mental status remains clear, provided they are adequately oxygenated.

How Is Wound Botulism Diagnosed?

Toxin assays are a standard part of diagnostic testing for wound botulism; these tests have a sensitivity of 33 to 44 percent and require a lab and adequate testing capabilities. When compared to the neuromuscular transmission studies that offer 100 percent sensitivity, the traditional toxin assays are time-consuming and less accurate.

Nevertheless, neither of the studies is suitable for acute diagnosis due to delays in obtaining results. Efforts to find a rapid diagnostic tool have shown some promise in creating a sensitive and specific test in the form of polymerase chain reaction (PCR)- based assays, immunoenzymatic assays, and bead-based suspension arrays.

What Is the Treatment for Wound Botulism?

  • Respiratory impairment and its associated complications caused by wound botulism are life-threatening; affected individuals are hospitalized, immediately given antitoxin, and are supervised closely.

  • A popular antitoxin for botulism is Equine (it is a botulism antitoxin bivalent). It is a refined and concentrated preparation of horse globulins modified by enzymatic digestion and contains phenol 0.4 percent as a preservative.

  • This is used in the treatment of type A and type B botulism. The best results with the antitoxin are seen when given earlier in the disease in very large doses.

  • Another antitoxin of choice is the heptavalent botulinum antitoxin. It is known to prevent all seven botulinum toxin types.

  • The antitoxins will not reverse already established neurological deficits; they will, however, prevent the progression of the disease. Recovery is lengthy and involves the regeneration of new neuromuscular connections.

  • In cases of respiratory failure, mechanical ventilation, and supportive care are given as adjuvant therapy.

  • Antibiotic therapy with Penicillin and Metronidazole can be prescribed to treat secondary infection; antibiotics like Clindamycin and Aminoglycoside should be avoided as these can worsen muscle weakness.

  • Adjuvant therapy also includes surgical debridement of the wound with irrigation to remove the source of the toxin.

Conclusion:

Wound botulism is a life-threatening disease with rapid progression. Swift evaluation, clinical diagnosis, and initial treatment play an important role in preventing severe complications, including the death of the patient. Emergency physicians should have a high clinical suspicion and should be able to recognize the early signs and symptoms of the disease.

Dr. Kaushal Bhavsar
Dr. Kaushal Bhavsar

Pulmonology (Asthma Doctors)

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