Wound botulism in drug addicts in the United Kingdom

Adulterants in illicit drugs: a review of empirical evidence

Widespread public perception is that illicit drugs contain substances that are a serious risk to health, even though adulterants are often not considered in clinical or forensic toxicology. This review attempts to present an evidence-based overview of adulterants in illicit drugs, and their associated toxicity. Adulterants are deliberately added to increase bulk, enhance or mimic a pharmacological effect, or to facilitate drug delivery. Those present unintentionally are as a result of poor manufacturing techniques. From the reports gathered, adulterants are predominantly substances which are readily available, commonly being caffeine, procaine, paracetamol, and sugars. These are likely to have minimal impact on users' health at low dosages. Other adulterants, particularly in injectable drugs, have the potential to cause serious health issues, but the quantities reported, such as strychnine in heroin, are not life-threatening. The most commonly identified bacterial contaminants identified are Bacillus and Clostridium species. When death or serious illness due to adulteration occurs, circulation of information is particularly vital, such as in the USA regarding heroin and cocaine adulterated with fentanyl, and in Scotland recently regarding anthrax contaminated heroin. The complex interactions of supply, demand, and control of illicit drugs have a tangible impact on their adulteration. Continuing vigilance and the circulation of information is, therefore, desirable as a public health issue. As part of that strategy, analyses performed for adulterants needs to be encouraged, which are considerably limited in number and scope at the moment.

Wound botulism from heroin skin popping

Following the introduction of black tar heroin mainly from Mexico in the 1980s, cases of wound botulism dramatically increased in the western United States. Contamination with spores of Clostridium botulinum of black tar heroin occurs along the distribution line. The heating of heroin powder to solubilize it for subcutaneous injection ("skin popping") does not kill the spores. The spores germinate in an anaerobic tissue environment and release botulinum toxin type A or B. Unless skin abscesses are found in the patient, the clinical diagnosis is often challenging. Facilitation of the compound muscle action potential by repetitive nerve stimulation at 20 to 50 Hz is an important and rapid diagnostic test. Definite diagnosis is made by detection of botulinum toxin in serum or isolation of C botulinum from the abscess. Early treatment with equine ABE botulinum antitoxin obtained from the Centers for Disease Control and Prevention often shortens the time on a ventilator.

Pharmacologic and toxicologic evaluation of C. novyi-NT spores

Clostridium novyi-NT (C. novyi-NT) spores have been shown to be potent therapeutic agents in experimental tumors of mice and rabbits. In the present study, pharmacologic and toxicologic studies were performed to better understand the factors influencing the efficacy and toxicity of this form of therapy. We found that spores were rapidly cleared from the circulation by the reticuloendothelial system. Even after large doses were administered, no clinical toxicity was observed in healthy mice or rabbits. The spores were also not toxic in mice harboring poorly vascularized non-neoplastic lesions, including myocardial infarcts. In tumor-bearing mice, toxicity appeared related to tumor size and spore dose, as expected with any bacterial infection. However, there was no laboratory or histopathologic evidence of sepsis, and the toxicity could be effectively controlled by simple hydration.

Bacteriological skin and subcutaneous infections in injecting heroin users-relevance for custody

Forensic medical examiners, custody nurses and police not infrequently come into physical contact with injecting heroin users whose injection sites maybe infected. Karch evaluated published reports on bacteriological findings at infected injection sites in drug users in 1996. Studies were then 10 years out of date. Recent concern has been about unexplained deaths in injecting heroin users, partly attributed to toxins produced by Clostridium novyii, Clostridium perfringens (welchii) and Clostridium botulinum. In response to this epidemic Lambeth, Southwark and Lewisham Health Authority (London, UK) urged investigation and treatment of injection site infection in heroin users within their area; circularising police stations and general practices with an official notice. In response, I followed up and treated in general practice 35 injecting heroin users with injection site infection presenting as detainees at two South London police stations. All swabs taken had a 48 hour incubation for anaerobic bacteria. At audit, no spore forming anaerobes were found. Just under 25% had non spore forming anaerobes such as bacteroides. Just over 50% had staphylococci in the injection site infection. Just under 20% had streptococci, half of which were beta haemolytic, a possible contact risk of infection being erysipelas, cellulitis, impetigo or conjunctivitis. No comparable studies were found but a study in New York in 1984 tabulated bacteriological findings of soft tissue infections in 29 hospitalised parenteral drug users. They found similar proportions of staphylococci, far more with streptococci, hardly any with non spore forming anaerobes and one case of spore forming anaerobic clostridium perfringens.

Efficient DNA fingerprinting of Clostridium botulinum types A, B, E, and F by amplified fragment length polymorphism analysis

Amplified fragment length polymorphism (AFLP) analysis was applied to characterize 33 group I and 37 group II Clostridium botulinum strains. Four restriction enzyme and 30 primer combinations were screened to tailor the AFLP technique for optimal characterization of C. botulinum. The enzyme combination HindIII and HpyCH4IV, with primers having one selective nucleotide apiece (Hind-C and Hpy-A), was selected. AFLP clearly differentiated between C. botulinum groups I and II; group-specific clusters showed <10% similarity between proteolytic and nonproteolytic C. botulinum strains. In addition, group-specific fragments were detected in both groups. All strains studied were typeable by AFLP, and a total of 42 AFLP types were identified. Extensive diversity was observed among strains of C. botulinum type E, whereas group I had lower genetic biodiversity. These results indicate that AFLP is a fast, highly discriminating, and reproducible DNA fingerprinting method with excellent typeability, which, in addition to its suitability for typing at strain level, can be used for C. botulinum group identification.

Wound botulism in the UK and Ireland

There are three main, naturally occurring, epidemiological types of botulism: food-borne, intestinal colonization (infant botulism) and wound botulism. The neurological signs and symptoms are the same for all three epidemiological types and may include respiratory paralysis. Wound botulism is caused by growth of cells and release of toxin in vivo, is associated with traumatic wounds and abscesses and has been reported in drug users, such as those injecting heroin or sniffing cocaine. Up to the end of 1999 there were no confirmed cases of wound botulism in the UK. Between the beginning of 2000 and the end of December 2002, there were 33 clinically diagnosed cases of wound botulism in the UK and Ireland. All cases had injected heroin into muscle or by 'skin popping'. The clinical diagnosis was confirmed by laboratory tests in 20 of these cases. Eighteen cases were caused by type A toxin and two by type B toxin.

Cutaneous complications of intravenous drug abuse

Injection drug abuse is a world-wide problem responsible for numerous minor to life-threatening and fatal complications. The skin is the tissue most evidently affected by intravenous drug addiction. A wide spectrum of cutaneous complications may occur in intravenous drug users. These include acute or delayed local complications, hypersensitivity reactions, cutaneous manifestations of systemic infections or becoming the site of toxigenic infections. Between 1996 and 2001, in our institution in south-eastern France, we observed cutaneous complications after crushed buprenorphine tablet injections in 13 patients. This paper reviews and classifies adverse effects of parenteral drug abuse on the skin.

Autopsy findings in an outbreak of severe systemic illness in heroin users following injection site inflammation: an effect of Clostridium novyi exotoxin?

CONTEXT

An epidemic of unexplained illness among injecting drug users characterized by injection site inflammation and severe systemic toxicity occurred in Ireland and the United Kingdom from April to August 2000. One hundred eight persons became ill, and 43 persons died. In Dublin, 8 of 22 patients died. Six of the 8 fatal cases were epidemiologically linked to a source of heroin. Most had experienced local injection site lesions for 7 to 14 days before developing a rapidly fatal systemic illness characterized by hypotension, thirst, pulmonary edema, pericardial and pleural effusions, and leukocytosis.

OBJECTIVE

To document the clinical course and autopsy findings of the fatal cases in Dublin.

DESIGN

To study the clinical, autopsy, microbiologic, and toxicologic findings from the 8 fatal cases in Dublin.

RESULTS

In Dublin, there were 6 men and 2 women who were fatally involved in the epidemic, with the mean age being 34 years (range, 22-51 years). The injection site inflammations involved the buttock (n = 4), leg, iliac region, arm, and a Portacath site. At autopsy, the local lesions were ulcerated, swollen, and indurated but were inconspicuous in 2 patients. All the deceased had pulmonary edema. There were pleural effusions in 7, 2 of whom had pericardial effusions. Five had prominent left ventricular subendocardial hemorrhages. Five had splenomegaly. Microscopy showed pulmonary edema and a granulocytic reaction mainly in the spleen, marrow, and myocardium. Toxicology showed a range of narcotic drugs in the toxic or fatal range. Clostridium novyi type A, a fastidious toxin-producing anaerobe, was identified in 2 cases.

CONCLUSION

The clinicopathologic findings of a local inflammatory lesion followed 7 to 14 days later by a rapidly fatal systemic illness are consistent with the effect of exotoxin produced by organisms growing in the local inflammatory site. Clostridium novyi-derived exotoxin is the likely cause of such a syndrome, although the fastidious organism was isolated from only 2 of 8 cases (from none of the 14 surviving patients and from only 13 of 60 cases in Scotland). In the setting of an epidemic, the toxic and fatal range blood levels of narcotics are unlikely to explain these events, and no other candidate organism could be isolated. The heroin is likely to have come from Afghanistan, but local contamination at a putative distribution site in the United Kingdom is more likely than international terrorism to be the initiating factor.

Botulism as a cause of respiratory failure in injecting drug users

BACKGROUND

Wound botulism occurs as a consequence of inoculation of Clostridium botulinum spores into a wound.

AIM

To describe such a case of wound botulism.

RESULTS

A 23-year-old drug-injecting user presented with bulbar symptoms and progressive signs over a three-day period. The diagnosis of botulism was suspected and was treated with large doses of penicillin and botulinum antitoxin. The diagnosis was confirmed by the presence of serum botulinum toxin A.

CONCLUSION

Physicians should be aware of the association of botulism in injecting drug users, particularly in Ireland.

Amplified fragment length polymorphism (AFLP) analysis of Clostridium novyi, C. perfringens and Bacillus cereus isolated from injecting drug users during 2000

As part of the follow-up investigations associated with an outbreak of severe illness and death among illegal injecting drug users during 2000, 43 cultures of Clostridium novyi type A, 40 C. perfringens type A and 6 isolates of Bacillus cereus were characterised by amplified fragment length polymorphism (AFLP) analysis. Among the 43 C. novyi isolates, 23 different AFLP profiles were detected. The same AFLP profile was detected in isolates from 18 drug users investigated during 2000 from Scotland, England, the Republic of Ireland and Norway and a wound from a patient in 2000 who was not identified as a drug user. Unique AFLP profiles were obtained from four drug users from England and the Republic of Ireland, 10 historical isolates from culture collections, an isolate from food (1989) and three isolates from wounds (1995, 1991, 1988). The 40 C. perfringens isolates were from 13 drug users, the contents of one syringe and two samples of heroin. Sixteen AFLP types of C. perfringens were distinguished and there was little evidence for commonality among the isolates. The AFLP types of C. perfringens from heroin differed and were unique. Six isolates of B. cereus were from four drug users and two samples of heroin. Four different AFLP patterns were distinguished. Three AFLP types were isolated from four drug users. B. cereus isolates from an aspirate and a heroin sample collected from the same drug user were identical, and were also indistinguishable from an isolate from a groin infection in a second drug user. The AFLP type of the isolate from a second and unrelated heroin sample was unique. The AFLP results showed no or very limited evidence for commonality between the different isolates of B. cereus and C. perfringens. In marked contrast, the C. novyi isolates from the majority of the drug users during 2000 were homogeneous, suggesting a common source or clonal selection of a C. novyi type, or both, which either had an adaptive advantage in spore germination, survival or growth following the drug preparation and the injection procedure, or produced a more severe clinical presentation.

An investigation into the microflora of heroin

In 2000, an unusual increase of morbidity and mortality among illegal injecting drug users in the UK and Ireland was reported and Clostridium novyi was identified as the likely source of the serious infection, although infections due to C. botulinum and Bacillus cereus were also reported. Because heroin was a possibile source of infection, this study investigated the microflora of heroin samples seized in England during 2000 and 2002. Two methods were developed for the examination of the microflora of heroin. The first consisted of suspension of the drug in maximum recovery diluent (MRD) which was inoculated directly into Clostridium Botulinum Isolation Cooked Meat Broth (CBI). The second method rendered the heroin soluble in citric acid, concentrated particulate material (and bacterial cells) by filtration and removed heroin residues by washing with citric acid and phosphate-buffered saline before placing the filter in CBI broth. Duplicate CBI broths from both methods were incubated without heating and after heating at 60 degrees C for 30 min. Subcultures were made after incubation for 7 and 14 days on to eight different solid media. The methods were evaluated with heroin samples spiked with either C. botulinum or C. novyi spore suspensions; recovery of 10 spores in the original sample was demonstrated. Fifty-eight heroin samples were tested by citric acid solubilisation and 34 by the MRD suspension technique. Fifteen different gram-positive species of four genera were recognised. No fungi were isolated. Aerobic endospore-forming bacteria (Bacillus spp. and Paenibacillus macerans) were the predominant microflora isolated and at least one species was isolated from each sample. B. cereus was the most common species and was isolated from 95% of all samples, with B. licheniformis isolated from 40%. Between one and five samples yielded cultures of B. coagulans, B. laterosporus, B. pumilus, B. subtilis and P. macerans. Staphylococcus spp. were isolated from 23 (40%) samples; S. warneri and S. epidermidis were the most common and were cultured from 13 (22%) and 6 (10%) samples respectively. One or two samples yielded cultures of S. aureus, S. capitis and S. haemolyticus. The remainder of the flora detected comprised two samples contaminated with C. perfringens and two samples with either C. sordellii or C. tertium. Multiple bacterial species were isolated from 43 (74%) samples, a single species from the remaining 15. In 13 samples B. cereus alone was isolated, in one B. subtilis alone and in one sample B. pumilus alone. C. botulinum and C. novyi were not isolated from any of the heroin samples. Recommendations for the optimal examination of the microflora of heroin are given.

Injecting drug use: implications for skin and wound management

This article, the first of two parts, introduces the difficulties facing nurses working with injecting drug users with skin problems. Drug abuse is increasing globally, and has huge implications for healthcare practitioners. Increasing numbers of tissue viability nurses are also encountering drug injection-induced wounds in their practice, but there is a lack of evidence for management of chronic skin problems in this patient group. Together with rising numbers of injecting drug users, there are increased health implications such as bacteraemia, septicaemia, amputation and skin breakdown. Abscesses and chronic wounds as well as prolonged leg ulceration are common. Drug users may demonstrate chaotic lifestyles, which may inhibit access to usual healthcare provision. Issues relating to healing of these wounds are explored. The second part, which will appear in the next Tissue Viability Supplement, will describe the development of a specialist wound care clinic for homeless drug users.