Bilateral Vocal Cord Paralysis and Respiratory Failure Secondary to Wound Botulism From Black Tar Heroin

Abstract

INTRODUCTION: Botulism is a rare form of neuromuscular junction (NMJ) paralysis caused by one of eight distinct toxins produced by the bacterium Clostridium botulinum. Typically associated with infants and poorly preserved foods, botulism may be acquired via gastrointestinal absorption, wound infections, airborne inhalation or iatrogenic causes. We report a case of lifethreatening wound botulism following injection of black tar heroin initially presenting with isolated bilateral vocal cord paralysis. CASE PRESENTATION: 31 yo male with a history of asthma and cocaine/amphetamine abuse presented with dysarthria, globus sensation and dyspnea. He denied intravenous drug use. Initial exam revealed a high-pitched voice with decreased phonation. Neuro exam was otherwise unremarkable. ENT performed laryngoscopy which revealed bilateral vocal cord paralysis. CT neck and MRI brain were negative for infection and stroke. Patient was admitted to the ICU upon which he developed progressive weakness without fatigability of his upper extremities, mydriasis, and poor respiratory effort with impending respiratory failure, prompting intubation and subsequent tracheostomy. During intubation, a syringe with black tar heroin was found on his gurney. He was treated with heptavalent antitoxin and penicillin G out of concern for wound botulism. EMG and nerve conduction studies (NCS) confirmed pre-synaptic NMJ pathology. Type A botulinum toxin was confirmed via serum assays by the CDC. His weakness and vocal cord paralysis resolved after 3 weeks of treatment, documented by EMG, NCS and endoscopy permitting liberation from the ventilator. His tracheostomy was decannulated 4 weeks after admission. He is now undergoing rehabilitation. DISCUSSION: Botulism classically presents with symptoms of descending paralysis including extraocular muscle palsies and other cranial nerves dysfunction, followed by progressive respiratory and extremity muscle weakness. Lab diagnosis is made via serum assays and testing of stool, vomitus, contaminated food or wounds. EMG studies aid diagnosis by distinguishing botulism from other NMJ disorders including myasthenia gravis and Lambert-Eaton syndrome. Treatment for botulism involves timely diagnosis, respiratory support, heptavalent antitoxin, and Penicillin G. CONCLUSIONS: Botulism is rare and can be difficult to diagnose in atypical presentations. This patient did not present with classic cranial nerve involvement but with isolated bilateral vocal cord paralysis instead. History and exam demonstrated weakness without fatigability, an important clinical factor that distinguishes botulism from other NMJ disorders. Timely recognition of progressive symptoms allowed quick administration of life-saving therapies. Botulism should be considered in the differential diagnosis of vocal cord paralysis.