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Botulism, Scotland 2015: are we recognising it?
M. Day [1], M. G. Booth [1], G. Penrice [2], L. Donaldson [1]
1. Glasgow Royal Infirmary (GRI), Glasgow, UK
2. Public Health Unit, Gartnavel Royal Hospital , Glasgow, UK
Botulism is a rare condition caused by the toxin produced by
Clostridium botulinum, or germination of C. botulinum spores in
wounds. Across Europe, most wound botulism is now associated with
drug injection, especially muscle popping [1]. Between 21.12.14 and
20.02.15, there were 24 confirmed, or probable cases of botulism in
people who inject drugs (PWIDs) in Scotland. All had recent history
of heroin injection with accidental or intentional subcutaneous or
intramuscular injection [2].
Epidemiology & Interventions
Table 1- Demographic and clinical history of botulism cases, GRI
n
Sex
Age
1
M
35
2
F
41
3
F
40
4
M
30
5
F
39
Clinical features/ skin
abscesses
Dyspnoea, ataxia, ptosis,
dysarthria, dysphagia,
hypoxic cardiac arrest
Dysphagia, laryngeal flaccid
paralysis, ptosis
Dyspnoea, dysphagia,
stridor, thigh abscess
Diplopia, dysarthria,
respiratory failure, thigh
abscesses
Dysarthria, dysphagia,
respiratory failure, skin
abscesses
Mechanical
Ventilation
Yes
Outcome
Yes
Alive
Yes
Alive
Yes
Alive
Yes
Alive
Died
As this is a rare condition, suspecting botulism is key to instituting
timely treatment. Wound infection has an incubation period of 4-14
days. Symptoms are of progressive central weakness; blurred vision,
ptosis, dysphagia, dysarthria and stridor1. Consequently, ICU referral
often occurs late e.g. complete airway obstruction in one instance and
respiratory arrest in another.
Health Protection Scotland (HPS) and the Police are attempting to
trace the source of the outbreak, assumed to be a contaminated batch
of heroin. Public health measures have included interviewing patients
and advising PWIDs to smoke, rather than inject, heroin.
Discussion
Meanwhile, Botulism should be part of the differential diagnosis in
any PWID presenting with blurred vision, ptosis, dysphagia,
dysarthria or other muscle weakness and should be referred for prompt
Critical Care review. Biological samples should be taken prior to
antitoxin and antibiotics administration. Public Health should also be
informed of all suspected cases [3].
References
1. European Centre for Disease Prevention and Control. Annual
Epidemiological Report 2014. Botulism Pages 10-14.
http://www.ecdc.europa.eu/en/publications/Publications/foodwaterborne-diseases-annual-epidemiological-report-2014.pdf
2. Health Protection Scotland. HPS Weekly Report “Botulism alert
for people who inject drugs- update. 20th January, 2015. Volume 49
No. 2015/03 ISSN 1753-4224 (Online)
http://www.hps.scot.nhs.uk/documents/ewr/pdf2015/1503.pdf
3. Public Health England. Shooting Up: infections among people
who inject drugs in the UK, 2014.
https://www.gov.uk/government/uploads/system/uploads/attachment_
data/file/370707/Shooting_Up_2014.pdf