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botulism

An acute, potentially fatal disease resulting from ingestion of Clostridium botulinum or Clostridium botulinum toxin. Etiology: - exposure to home-canned foods - infant botulism with honey - in vivo toxin production after spore germination following ingestion - wound contamination Epidemiology: - 9 cases of wound botulism associated with injecting heroin from Sept 2017 to May 2018 in San Diego county [] Pathology: - several toxins (A-G) - respiratory dysfunction (dyspnea) may result from upper airway obstruction vs diaphragm weakness Clinical manifestations: - symptoms present within 24-72 hours of toxin exposure [3] - incubation period 2 hours-8 days [3] - sudden onset of symptoms - afebrile with clear sensorium - cranial nerve palsy; cranial nerves affected early - ocular findings a) sluggisly reactive or non-reative pupils* b) diplopia c) mydriasis d) ptosis e) nystagmus - symmetric descending flaccid paralysis - weakness - headache - dizziness - dysphagia - dysarthria, dysphonia - abdominal pain - constipation - nausea/vomiting - diarrhea - irregular respirations, respiratory dysfunction, dyspnea - swollen tongue - hyporeflexia - ataxia - infants < 6 months of age: - flaccid paralysis, hypotonia, ptosis, weak cry or suck Laboratory: 1) Clostridium botulinum toxin in specimen: a) Clostridium botulinum toxin in serum b) food c) feces Clostridium botulinum toxin in stool d) gastric aspirate 2) Clostridium botulinum toxin DNA 3) injection of suspected food into mice (mice die if food contains botulinum B toxin) 4) Clostridium botulinum toxin A Ab in serum 5) Clostridium botulinum culture Differential diagnosis: 1) Guillain Barre syndrome (ascending symmetric weakness) 2) Myasthenia gravis: pupils are normal 3) Lambert-Eaton syndrome 4) tick paralysis 5) stroke 6) intoxication from drugs, heavy metals, etc. Management: 1) supportive - Trendelenberg position may help with ventilation 2) botulinum antitoxin - trivalent equine antitoxin (toxin A, toxin B, toxin E) - does not reverse paralysis [3] 3) human botulism immune globulin [2]

Interactions

disease interactions

Related

botulinum toxin Clostridium botulinum Guillain-Barre syndrome (GBS) Lambert-Eaton myasthenic syndrome (LEMS) myasthenia gravis tick paralysis toxicity; poisoning; overdose

General

bacterial infection food poisoning (foodborne disease) polyneuropathy

References

  1. DeGowin & DeGowin's Diagnostic Examination, 6th edition, RL DeGowin (ed), McGraw Hill, NY 1994, pg 869-70
  2. Arnon SS et al, Human botulism immune globulin for the treatment of infant botulism. N Engl J Med 2006, 354:462 PMID: 16452558
  3. Medical Knowledge Self Assessment Program (MKSAP) 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2006, 2009, 2012, 2015, 2018, 2021.
  4. Cherington M. Botulism: update and review. Semin Neurol. 2004 Jun;24(2):155-63. PMID: 15257512
  5. David WS, Temin ES, Kraeft JJ, Hooper DC. Case records of the Massachusetts General Hospital. Case 3-2015. A 60-year-old woman with abdominal pain, dyspnea, and diplopia. N Engl J Med. 2015 Jan 22;372(4):364-72 PMID: 25607430 http://www.nejm.org/doi/full/10.1056/NEJMcpc1410936
  6. Zhang JC, Sun L, Nie QH. Botulism, where are we now? Clin Toxicol (Phila). 2010 Nov;48(9):867-79. Review. PMID: 21171845
  7. Peak CM, Rosen H, Kamali A, et al. Wound Botulism Outbreak Among Persons Who Use Black Tar Heroin - San Diego County, California, 2017-2018. MMWR Morb Mortal Wkly Rep 2019;67:1415-1418. https://www.cdc.gov/mmwr/volumes/67/wr/mm675152a3.htm
  8. CDC's botulism treatment program http://www.bt.cdc.gov/agent/botulism