Ria Memoria

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Clostridium
Botulinum
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 Clostridium botulinum is a strictly anaerobic, spore-forming, gram-

positive rod that elaborates a potent exotoxin.

 The spores are capable of tolerating temperatures of 100 C for

hours, whereas moist heat at 120 C usually destroys them.

 Eight separate toxin types (A, B, C (alpha), C (beta), D, E, F, and G)

have been described.

 All are neurotoxins with identical mechanism of action.

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Sources

 Foodborne botulism usually results from consumption of contaminated

preserved food—canned meat and meat products, fruits, vegetables,
pickles, and fish. A bulging can with peculiar tasting contents should
raise the suspicion of botulism.

 Wound botulism results from wound infection with Cl. Botulinum.

 Infant botulism most probably is caused by contaminated honey. The

US Centers for Disease Control stipulate that infants under the age of
6 months not be given honey, and the Honey Industry Council has
extended that limit to one year.
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MOA

 Three steps are necessary for toxin-induced neuromuscular

blockade: transport across the intestinal wall into the serum;
binding to neuronal receptors; and internalisation of bound toxin,
an irreversible step leading to impairment of neurotransmitter
release and resultant neuromuscular blockade. The result is
hypotonia with a descending symmetric flaccid paralysis; the
blockade is most prominent at the cranial nerves, autonomic
nerves, and neuromuscular junction.
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Incubation Period

 About 12 to 36 hours (but can occur as early as 3 hours and as

late as 16 days), with a median report of symptoms at 3.2 days.

 Type E toxin has the shortest, and type B toxin the longest
incubation period.

 In general, the earlier the onset of symptoms, the more serious

the disease and the more protracted the course.
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Clinical Features
Food Borne

 This is usually caused in humans by types A, B, E, and rarely F. The initial phase of the disease
is often so subtle as to go unnoticed or misdiagnosed.

 Nausea, vomiting, thirst, abdominal pain. Abdominal cramps may be an early symptom of
foodborne botulism. Marked abdominal distension with absent bowel sounds may be present
due to paralytic ileus.

 Constipation; refusal to feed and diarrhoea have been reported in a few cases of paediatric
botulism.

 Ptosis, difficulty with visual accommodation, photophobia, mydriasis, and diplopia (due to ocular
paresis).

 Strabismus and nystagmus have also been reported.

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 Dry mouth,* soreness of throat due to drying of pharynx, dryness of lacrimal

secretions.

 Dysphonia, dysarthria, dysphagia.

 Urinary retention (especially in Type E botulism): due to cholinergic blockade.

 Cardiac arrest may occur in patients with respiratory failure. It is not known
whether arrest is secondary to hypoxia or due to a direct effect of botulinum
toxin on the myocardium.
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Wound Botulism

 This is a rare, life-threatening complication of trauma which occurs after spores

of Cl. botulinum have germinated in a wound and produced botulinum toxin
resulting in flaccid paralysis. It can also result from intravenous drug abuse.

 Of late, cocaine and heroin (especially “black tar heroin” which is often injected
subcutaneously) have been increasingly associated with cases of wound
botulism.

 Fever (usually associated with sinusitis, abscess, or tissue infection which acts
as the focus of infection).

 – Absence of GI manifestations.

 – Cranial nerve palsies resulting in ptosis, diplopia, poor accommodation,

ophthalmoplegia, dysphagia, dysphonia, and dysarthria.

 – Other neurological features such as descending flaccid paralysis, shortness

of breath, and respiratory failure
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Infant Botulism

 Infant botulism is said to be the commonest form of botulism.

 Of all the food items associated with infant botulism, honey is said to
be the commonest food source contaminated with Cl. botulinum
spores.

 Constipation, feeding difficulty, feeble crying, and a “floppy” baby with

decreased muscle tone, particularly of the neck and limbs. Loss of
facial grimacing, ophthalmoplegia, diminished gag reflex, dysphagia,
poor anal sphincter tone, and respiratory failure have also been
reported
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Diagnosis

 Laboratory analysis: Samples of serum, stool, vomitus, gastric

contents, and suspected food item should be tested for Cl.
botulinum as well as botulinum toxin.

 Tensilon test: Tensilon (edrophonium) is a rapid-acting

anticholinesterase used to differentiate botulism from
myasthenia gravis. 10 mg of the drug is injected IV slowly (1 to 2
mg at first, followed by the remainder over the next 5 minutes).
Muscle strength in myasthenia gravis will improve dramatically
within   to 1 minute, and last for about 5 minutes, while there will
be little or no improvement in botulism.
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 Electromyography: Assess health of muscles and nerve cells.

 Bedside spirometry to determine forced vital capacity (FVC) and inspiratory

force should be done sequentially in suspected patients.

 Wound botulism

 a. Laboratory analysis: Wound cultures and serum assays for botulinum toxin.

 b. Tensilon test.

 c. Electromyography.

 Infant botulism

 1. History: of honey ingestion.

 2. Clinical picture.

 3. Tensilon test: unreliable in infants.

 4. Stool analysis.
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Treatment

 Due to the serious nature of the illness, all cases of botulism must be
admitted to hospital and continuous monitoring done.

 An attempt should be made to evacuate the GI tract of spores and toxin

with the help of activated charcoal, emesis, gastric lavage, or catharsis,
if the patient is seen early. Presence of gag reflex must be ascertained.
If catharsis is decided upon, sorbitol is the cathartic of choice. Gut
decontamination is of course not applicable in wound botulism.

 Botulinum antitoxin: Trivalent botulinum antitoxin (types A, B, and E) is

an equine globulin preparation that is available in the West since the
1960s, but does not appear to be produced in India.
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 Sensitivity testing: Skin or eye tests should be done prior to administration of the
antitoxin or serum, even if the patient has previously received the antitoxin.

 Skin test (in persons with allergic disposition)—0.05 mL of a 1:1000 dilution (in
saline), intracutaneously. Read the reaction in 5 to 30 minutes.

 – Skin test (in persons with allergic disposition)—0.1 ml of a 1:100 dilution (in saline),
intracutaneously. Read the reaction in 5 to 30 minutes.

 – Eye test—Except in small children, the eye test is easier to be done, and is more
specific. Instil a drop of a 1:10 dilution of antitoxin/serum in physiologic saline in 1
eye; instil a drop of physiologic saline in the other eye as a control. Positive reaction:
lacrimation and conjunctivitis appears in 10 to 30 minutes in the eye treated with the
antitoxin/serum.
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 Guanidine: The use of guanidine is controversial since it has low efficacy and high incidence of adverse effects. In case it
is considered appropriate, the recommended dose is 15 to 40 mg/kg/day orally until EMG improvement occurs at least in
the ocular muscles

 Penicillin: It is of no use in foodborne and infant botulism, but can be of substantial benefit in wound botulism. Penicillin G
is the preferred form.

 Human-derived botulism immune globulin (BIG) has recently been introduced in the West to treat infant botulism.

 The neuromuscular blockade antagonist, 4-aminopyridine has been used in addition to regular supportive care and
antitoxin therapy.

 Surgical debridement may be necessary for suspected wound botulism. High dose intravenous benzylpenicillin, along
with appropriate antitoxin administration, has been used effectively to treat patients with wound botulism.

 Supportive measures:

 a. Nutritional supplementation—oral feeds are contraindicated unless there is intact gag reflex.

 b. Respiratory support—forms the mainstay of treatment.

 c. Antibiotics should only be used to treat complications such as respiratory or urinary tract infections, or
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Prevention

 Avoid consuming improperly preserved home-canned foods, especially

vegetables such as green beans, asparagus, and peppers.

 Home-canning of vegetables should be done with a pressure cooker so as to

attain temperatures necessary to kill botulinum spores (> 100  C for 10 minutes).

 Jams and jellies can be safely home-canned without pressure cooker, since their
high sugar content will not encourage the growth of Cl. botulinum.

 Cooked foods should not be kept at temperatures of 4  C to 60  C for more than
4 hours.

 Boiling food for 10 minutes before eating destroys botulinum toxin.

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 Food contaminated by Cl. botulinum types A and B often looks

or smells abnormal due to action of proteolytic enzymes. If there
is any doubt, the food item must be discarded.* Alarmingly, food
contaminated with type E toxin usually looks and smells normal.

 Prevention of infant botulism can be done by thoroughly

washing foods and objects that are placed in a child’s mouth.
Honey must not be given to infants.
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Thank You!!!