Wound botulism in an intravenous drug user

A 46-year-old man with a longstanding history of intravenous heroin abuse presented with sudden onset of diplopia, unsteady gait, dysarthria, and progressive dyspnea. Clinical examination revealed multiple healing ulcerations and crusted erosions with surrounding post-inflammatory hyperpigmentation on both forearms, consistent with injection-site injury (Panel A). Neurologic evaluation demonstrated bilateral cranial nerve III, VI, and VII palsies, with evolving respiratory compromise in keeping with a descending pattern of paralysis (Panel B).