Wound Botulism

A 42-year-old man with a history of subcutaneous heroin use presented to the hospital with slurred speech, diplopia, and dysphagia. The physical examination showed bilateral ptosis (Panel A), a sluggish pupillary response to light, bilateral sixth-cranial-nerve palsies, and multiple skin abscesses on his arms and legs. Shortly after admission, the dysphagia progressed, necessitating intubation for airway protection. Single-fiber electromyography suggested a disorder of neuromuscular transmission, and a clinical diagnosis of wound botulism was made. He received empirical treatment with equine serum trivalent botulism antitoxin and antimicrobial therapy, and the abscesses were surgically débrided (Panel B). Subsequently, botulinum toxin was detected . . .