Wound botulism

Wound botulism is a rare but serious infectious disease caused by the bacterium Clostridium botulinum, which colonizes a wound and produces botulinum neurotoxin in vivo. Unlike foodborne botulism, the toxin is not ingested but rather produced locally at the site of an infected wound and then absorbed into the bloodstream. The toxin blocks the release of acetylcholine at neuromuscular junctions, leading to progressive descending flaccid paralysis. Wound botulism primarily affects the nervous system and skeletal muscles. It has become increasingly associated with injection drug use, particularly subcutaneous injection ("skin popping") of black tar heroin, as well as traumatic wounds and, rarely, surgical wounds. Key clinical features include cranial nerve palsies (diplopia, blurred vision, ptosis, dysarthria, dysphagia), symmetric descending weakness progressing from the head and neck to the trunk and extremities, and respiratory failure in severe cases. Unlike foodborne botulism, gastrointestinal symptoms such as nausea, vomiting, and diarrhea are typically absent. Patients may also present with a wound that appears infected, though the wound may sometimes appear deceptively benign. Fever may be present due to wound infection but is not caused by the toxin itself. The incubation period is typically 4 to 14 days after wound contamination. Treatment involves prompt administration of equine-derived heptavalent botulinum antitoxin to neutralize circulating toxin and prevent disease progression. Surgical debridement of the infected wound is essential to remove the source of toxin production, along with antibiotic therapy (typically penicillin or metronidazole) directed against Clostridium botulinum. Supportive care, including mechanical ventilation for respiratory failure, is often required. Recovery can take weeks to months as new nerve terminals must regenerate. Early recognition and treatment are critical, as delays in antitoxin administration are associated with worse outcomes and prolonged intensive care stays.

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