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To the Editor.—Dr Passaro and colleagues¹ may have incorrectly identified the source of Clostridium botulinum spores when searching for an explanation of an outbreak of wound botulism (WB) among injecting drug users (IDUs). The authors postulate that the source of the botulism spores is contaminated "black tar" heroin (BTH) injected subcutaneously ("skin-popping"). However, it is possible that the spores come from the soiled skin of IDUs and subsequently get inoculated subcutaneously or intramuscularly during the injecting process.

The number of subcutaneous injections and the amount of BTH injected monthly correlated with the increase of WB cases raises the possibility that the increased number of subcutaneous injections rather than the dose of BTH accounts for the increase in the rate of WB in skin-popping heroin users. However, the authors indicate that there was no significant difference between the rate of adequate skin cleansing in cases compared with controls. It is . . . [Full Text of this Article]

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