title: Rapid geographical clustering of wound botulism in Germany after subcutaneous and intramuscular injection of heroin.
abstract: BACKGROUND
  Wound infections due to Clostridium botulinum in Germany are rare and occur predominantly in heroin injectors, especially after subcutaneous or intramuscular injection of heroin ("skin popping"), which is contaminated with spores of C. botulinum. We report a rapid geographical clustering of cases in Germany in a region between Cologne, Bonn, and Aachen with wound botulism and consecutive systemic C. botulinum intoxication in intravenous drug users (IDUs) within 6 weeks in October and November 2005.
  
  
  METHODS
  A group of 12 IDUs with wound botulism after "skin popping."
  
  
  RESULTS
  Clinical data were available in 11 (92%) of 12 patients; in 7 (58%) of the 12 cases, there was cranial nerve involvement including mydriasis, diplopia, dysarthria, and dysphagia, followed by progressing symmetric and flaccid paralysis of proximal muscles of the neck, arms, trunk, and respiratory muscles. Mechanical respiratory support was necessary. Five of the IDUs were treated with antitoxin, but mechanical respiratory support could not be avoided. The mean ventilation duration was 27.4 days (range 6-77 days). In 4 patients (33%), mechanical ventilation could be avoided; two were treated with antitoxin.
  
  
  CONCLUSIONS
  This report describes rapid geographical clustering of wound botulism with severe respiratory complications in IDUs after "skin popping," which has not previously been reported either in Germany or any other European country. Based on these observations and those in other European countries, we conclude that there is a trend towards "skin popping," suggesting a change in injection practices in IDUs. Secondly, we conclude that the total number of cases with wound botulism is likely to increase because "skin popping" is the main risk factor.
authors.affiliation: Department of Neurology, University of Cologne, Kerpener Strasse 62, 50924 Cologne, Germany. Norbert.Galldiks@nf.mpg.de
authors.forename: Norbert
authors.initials: N
authors.lastname: Galldiks
authors.forename: Silke
authors.initials: S
authors.lastname: Nolden-Hoverath
authors.forename: Christoph M
authors.initials: CM
authors.lastname: Kosinski
authors.forename: Ulrike
authors.initials: U
authors.lastname: Stegelmeyer
authors.forename: Sylvia
authors.initials: S
authors.lastname: Schmidt
authors.forename: Christian
authors.initials: C
authors.lastname: Dohmen
authors.forename: Jens
authors.initials: J
authors.lastname: Kuhn
authors.forename: Kathrin
authors.initials: K
authors.lastname: Gerbershagen
authors.forename: Heiko
authors.initials: H
authors.lastname: Bewermeyer
authors.forename: Peter
authors.initials: P
authors.lastname: Walger
authors.forename: Rolf
authors.initials: R
authors.lastname: Biniek
authors.forename: Michael
authors.initials: M
authors.lastname: Neveling
authors.forename: Andreas H
authors.initials: AH
authors.lastname: Jacobs
authors.forename: Walter F
authors.initials: WF
authors.lastname: Haupt
mesh_terms: D000328:Adult; D001906:Botulism / Q000453:epidemiology* / Q000473:pathology; D003014:Clostridium botulinum / Q000302:isolation & purification; D005260:Female; D005858:Germany / Q000453:epidemiology; D006556:Heroin Dependence / Q000150:complications*; D006801:Humans; D007273:Injections, Intramuscular / Q000009:adverse effects*; D007297:Inpatients; D008297:Male; D014947:Wounds and Injuries / Q000382:microbiology*