title: Wound botulism associated with black tar heroin among injecting drug users.
abstract: BACKGROUND
  Wound botulism (WB) is a potentially lethal, descending, flaccid, paralysis that results when spores of Clostridium botulinum germinate in a wound and elaborate neurotoxin. Since 1988, California has experienced a dramatic increase in WB associated with injecting "black tar" heroin (BTH), a dark, tarry form of the drug.
  
  
  OBJECTIVE
  To identify risk factors for WB among injecting drug users (IDUs).
  
  
  METHODS
  Case-control study based on data from in-person and telephone interviews.
  
  
  METHODS
  Case patients (n=26) were IDUs who developed WB from January 1994 through February 1996. Controls (n=110) were IDUs newly enrolled in methadone detoxification programs in 4 counties.
  
  
  METHODS
  Factors associated with the development of WB.
  
  
  RESULTS
  Among the 26 patients, the median age was 41.5 years, 15 (58%) were women, 14 (54%) were non-Hispanic white, 11 (42%) were Hispanic, and none were positive for the human immunodeficiency virus. Nearly all participants (96% of patients and 97% of controls) injected BTH, and the mean cumulative dose of BTH used per month was similar for patients and controls (27 g and 31 g, respectively; P=.6). Patients were more likely than controls to inject drugs subcutaneously or intramuscularly (92% vs 44%, P<.001) and used this route of drug administration more times per month (mean, 67 vs 24, P<.001), with a greater cumulative monthly dose of BTH (22.3 g vs 6.3 g, P<.001). A dose-response relationship was observed between the monthly cumulative dose of BTH injected subcutaneously or intramuscularly and the development of WB (chi2 for linear trend, 26.5; P<.001). In the final regression model, subcutaneous or intramuscular injection of BTH was the only behavior associated with WB among IDUs (odds ratio, 13.7; 95% confidence interval, 3.0-63.0). The risk for development of WB was not affected by cleaning the skin, cleaning injection paraphernalia, or sharing needles.
  
  
  CONCLUSIONS
  Injection of BTH intramuscularly or subcutaneously is the primary risk factor for the development of WB. Physicians in the western United States, where BTH is widely used, should be aware of the potential for WB to occur among IDUs.
authors.affiliation: Division of Communicable Disease Control, California Department of Health Services, Berkeley 94704, USA. dpass@ix.netcom.com
authors.forename: D J
authors.initials: DJ
authors.lastname: Passaro
authors.forename: S B
authors.initials: SB
authors.lastname: Werner
authors.forename: J
authors.initials: J
authors.lastname: McGee
authors.forename: W R
authors.initials: WR
authors.lastname: Mac Kenzie
authors.forename: D J
authors.initials: DJ
authors.lastname: Vugia
mesh_terms: D000328:Adult; D000368:Aged; D001906:Botulism / Q000453:epidemiology / Q000209:etiology*; D002140:California / Q000453:epidemiology; D016022:Case-Control Studies; D005260:Female; D003932:Heroin; D006801:Humans; D016013:Likelihood Functions; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D012044:Regression Analysis; D012307:Risk Factors; D018709:Statistics, Nonparametric; D015819:Substance Abuse, Intravenous / Q000150:complications*; D014946:Wound Infection / Q000453:epidemiology / Q000209:etiology*
chemical_list: D003932:Heroin