BOTULISM ATTACKING DRUG USERS\Rare form of disease festers in punctures.

Byline: Jane E. Allen Associated Press

Cases of a rare disease caused by the deadliest toxin known to man are on the increase and appear concentrated among heroin users in California, health officials report.

Last year, California health authorities confirmed 21 cases of wound botulism in heroin users, and a couple more cases are pending. At least 15 of the cases have occurred since August.

"We're not seeing wound botulism anywhere else in the country with injecting drug users," said Fred Angulo, a medical epidemiologist with the National Center for Infectious Diseases at the federal Centers for Disease Control in Atlanta. "It's quite a phenomenon in the state of California."

Botulism toxin is produced by spores from Clostridium botulinum, a close relative of the tetanus bacterium that's also found in soil throughout the country.

The toxin is so deadly that just a spoonful slipped into Los Angeles' water supply could "knock off everybody," says Dr. S. Benson Werner, state medical epidemiologist and chief of the disease investigation section of the California Department of Health Services.

Botulism is best known as a form of food poisoning from products that haven't been properly processed, especially home-canned vegetables and fruit. There were three such cases in California last year. It also occurs in the intestines of infants who have ingested botulism spores but lack the disease-fighting powers of adults. That accounted for 36 California cases last year.

But the biggest growth has been in cases of botulism that festered in wounds of drug users. Wound botulism is caused when the spores get into an injection puncture, germinate and release deadly toxin.

Once the toxin enters the bloodstream, it creates paralysis that typically begins with the drooping of both eyelids, blurred or double vision and a dry sore throat. Without medical intervention, death occurs when it paralyzes the muscles needed for breathing.

Although there's no cure, doctors treat it with a combination of antitoxin and antibiotics.

Wound botulism connected to injectable drugs first was reported in 1982 in New York City. It turned up in California in 1988.

Since then, California cases have grown at a disturbing rate: one in 1990, two in 1991, three in 1992, four in 1993 and 11 in 1994, according to a report published this past week in the Journal of the American Medical Association. Those 11 cases accounted for all the wound botulism cases reported nationally among 53 confirmed adult cases in 1994, according to CDC figures.

Although the CDC doesn't have 1995 totals, wound botulism appears confined to California. Two reports of drug-related wound botulism from Arizona have not been confirmed by laboratory tests, Angulo said.

California cases occurred in chronic drug abusers who turn to injecting black tar heroin, a dark, gummy, cheaper form of the narcotic, into their skin when their veins have given out.

Experts can only conjecture that this form of the drug may be contaminated by botulinum spores.

"It may get contaminated near where the poppy fields are" or "later on when they mix the heroin with sugars and starches to bulk it up," Werner said.

Addicts may think that heating the heroin will sterilize it, but heat only kills the toxin. The spores survive, only to germinate and produce more toxin.

"This spore can persist in boiling temperatures for at least five hours," Werner cautioned.

A state heroin testing program has not yet turned up spores six samples, although the state is awaiting additional supplies from the federal Drug Enforcement Administration.

With heroin injection already associated with AIDS and hepatitis, the rise in wound botulism is giving authorities another reason to campaign against drug abuse and its expensive consequences.

Treatment includes one to two vials of antitoxin, derived from horse serum, that costs $700 a vial. The CDC absorbs the cost.

Antitoxin neutralizes any toxin circulating in the body, but can't reverse nerve damage. Over time, the body slowly regenerates some damaged nerve connections.

"Some people can be on a respirator three or four months and be in a hospital five months," Werner said. "Considering a lot of these people don't carry their own insurance, they wind up being very costly to the public sector."