Neurology Department, Texas Tech University Health Sciences Center, 4800 Alberta Avenue, El Paso, TX, 79905, USA.
Neurocrit Care. 2017 Dec;27(3):415-419. doi: 10.1007/s12028-017-0415-6.
Botulism is a rare potentially fatal and treatable disorder caused by a bacteria-produced toxin that affects the presynaptic synaptic membrane resulting in a characteristic neuromuscular dysfunction. It is caused by either the ingestion of the toxin or the bacteria, inhalation, or wound infection. We present our observations with a descriptive case series of wound botulism secondary to black tar heroin (BTH) injection.
We report a retrospective single-center case series of 15 consecutive cases of wound botulism presenting to University Medical Center of El Paso. Medical records where reviewed to obtain demographic information, clinical presentation, treatment, and outcome.
We identified fifteen patients with mean age of 47 years: twelve men, and three women. All had administered BTH through skin popping and had abscesses in the administration areas. By history, the most common symptoms were dysphagia (66%), proximal muscle weakness of upper and lower extremity (60%), neck flexor muscle weakness (33%), ophthalmoplegia (53%), bilateral ptosis (46%), dysarthria (53%), double vision (40%), blurred vision (33%), and dry mouth (20%). During the examination, the most common features noted were: proximal muscle weakness of upper and lower extremities (73%), ophthalmoplegia (53%), ptosis (46%). In patients with documented wound botulism, the pupils were reactive in 46%. All patients required mechanical ventilation and were treated with the trivalent antitoxin. Eleven patients (73.3%) were discharged home, two were transferred to a skill nursing facility, and two were transferred to long-term acute care facility.
In our patients, BTH injection, involving the action of injecting under the skin acetylated morphine derivatives (mostly 6-monoacetylmorphine and 3-monoacetylmorphine), was associated with the development of botulism. The availability of BTH at the US-Mexican border is not surprising since it is frequently produced in Latin America. Its association with the development of botulism should be recognized early to allow a prompt diagnosis and treatment with the antitoxin. A clinical feature worth noting is the presence of normal pupillary light reflex in nearly half of patients. Therefore, the presence of a normal pupillary response does not exclude the presence of wound botulism.
肉毒中毒是一种罕见的潜在致命性疾病，可以通过治疗来改善，由细菌产生的毒素引起，影响突触前突触膜，导致特征性的神经肌肉功能障碍。它是由摄入毒素或细菌、吸入或伤口感染引起的。我们通过黑焦油海洛因（BTH）注射引起的伤口肉毒中毒的描述性病例系列报告我们的观察结果。
我们报告了德克萨斯大学医学中心埃尔帕索分校的 15 例连续伤口肉毒中毒病例的回顾性单中心病例系列。查阅病历以获取人口统计学信息、临床表现、治疗和结果。
我们确定了 15 名平均年龄为 47 岁的患者：12 名男性，3 名女性。所有人都通过皮肤穿刺注射 BTH，并在注射部位出现脓肿。根据病史，最常见的症状是吞咽困难（66%）、上下肢近端肌肉无力（60%）、颈屈肌无力（33%）、眼肌瘫痪（53%）、双侧上睑下垂（46%）、构音障碍（53%）、复视（40%）、视力模糊（33%）和口干（20%）。在检查过程中，最常见的特征是：上下肢近端肌肉无力（73%）、眼肌瘫痪（53%）、上睑下垂（46%）。在有记录的伤口肉毒中毒患者中，瞳孔反应率为 46%。所有患者均需要机械通气，并接受三联抗毒素治疗。11 名患者（73.3%）出院回家，2 名患者转至技能护理机构，2 名患者转至长期急性护理机构。
在我们的患者中，BTH 注射，涉及在皮肤下注射乙酰化吗啡衍生物（主要是 6-单乙酰吗啡和 3-单乙酰吗啡），与肉毒中毒的发展有关。BTH 在美国-墨西哥边境的存在并不奇怪，因为它经常在拉丁美洲生产。应及早认识到其与肉毒中毒的发展有关，以便及时诊断和使用抗毒素治疗。值得注意的一个临床特征是近一半患者的瞳孔光反射正常。因此，正常的瞳孔反应并不能排除伤口肉毒中毒的存在。
