Heroin-Related "Wound Botulism" Found in San Diego

By Paul Gaita 01/08/19

Nine people have been hospitalized with the heroin-related illness in California.

ER doctors working on a patient with heroin-related wound botulism

An outbreak of a rare and life-threatening illness linked to black tar heroin use was discovered in San Diego, prompting health officials in the Southern California city to launch an investigation while warning doctors and IV users alike to be aware of the condition.

The Centers for Disease Control (CDC) reported that nine cases of wound botulism, which is caused by a toxic bacterium entering the body through a wound, were discovered between 2017 and 2018, which resulted in one fatality and intensive care treatment for all nine individuals.

Though the number of cases may seem relatively small, only 20 cases of wound botulism are reported per year for the whole of the United States, so the situation was cause for alarm for both state and national health care officials.

According to the CDC report, two patients with a history of using black tar heroin — so called because of its dark, sticky appearance, caused by crude and often contaminated processing — were believed to have contracted wound botulism though IV drug use.

The County of San Diego Public Health Services (COSD) issued an alert through the California Health Alert Network to notify Southern California doctors of the situation. A subsequent investigation by the COSD and the California Department of Health eventually found nine patients – eight confirmed and one probable – by April of 2018.

All nine were IV drug users, and seven reported using black tar heroin. Of the latter number, six reportedly injected the drug through "skin popping," or injecting the drug under the skin.

Symptoms of wound botulism typically manifest several days after injecting the contaminated drugs and may include double or blurred vision, slurred speech, dry mouth and muscle weakness.

If left unchecked, it can result in labored breathing and even paralysis. However, many of these symptoms coincide with signs of opioid use or overdose, and in four of the cases, the individuals were initially diagnosed with drug intoxication, and two were treated with the overdose reversal drug naloxone. 

Eventually, all of the patients were diagnosed with wound botulism and treated with heptavalent botulism antitoxin (BAT), and eight were transferred to long-term care facilities; the ninth patient declined further treatment. One of the eight died after nine days in long-term care.

The COSD issued health alerts in 2017 and 2018 notifying health care providers to inform IV drug users about the risks of contracting wound botulism and asking them to carefully observe patients reporting IV drug use history for symptoms. One day after the 2018 alert, clinicians reported additional cases of suspected wound botulism for two hospitalized patients.

The CDC's report concluded with a request for heightened awareness of the condition for both doctors and IV drug users, in light of the national opioid crisis.

Dr. Sayone Thihalolipavan, the deputy public health officer for San Diego County, reiterated the need for careful observation of IV drug patients.

"Even if they're seeking treatment, providers might not be recognizing it for what it is," he said. "Patients can think they're feeling out of whack due to the drug itself and not realize that the drug is actually contaminated."

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Paul Gaita lives in Los Angeles. He has contributed to the Los Angeles Times, Variety, LA Weekly, Amazon.com and The Los Angeles Beat, among many other publications and websites.