Botulism

N. Negrut, MD,
Infectious Disease Specialist, Teaching Assistant
Faculty of Medicine and Pharmacy, University of
Oradea
Botulism - acute neurologic disorder
 Neuroparalysis  neurotoxin
 Neurotoxin
 Clostridium botulinum.
 binds irreversibly the presynaptic
membranes of peripheral neuromuscular and
autonomic nerve junctions, blocks acetylcholine
release.
 Cure occurs following sprouting of new nerve
terminals.
 C. botulinum
 anaerobic gram-positive bacillus
 survives in soil and marine sediment by
forming spores
 in anaerobic conditions that permit
germination, it synthesizes exotoxin
(neurotoxin).
 Eight antigenically distinct C botulinum
toxins:
1. A  food botulism (humans)
2. B  food botulism (humans)
3. C (alpha)  animals
4. C (beta)  animals
5. D  animals
6. E  food botulism (humans)
7. F  rarely cause human disease
8. G  associated with sudden death but
not with neuroparalytic illness.
 Clinical presentations
 infant botulism ingested C botulinum spores (bee honey/soil)
 foodborne botulism ingested improperly canned or home-prepared foods
 wound botulism  contamination of a wound with C botulinum
Foodborne botulism – clinical manifestation
acute gastrointestinal illness + neurologic symptoms - fever

 incubation = 2 hours - 8 days  Involvement of cranial nerves IX, X,

 onset = abrupt or insidious. and XII:
 death can occur within 24 hours  dysarthria,
 Gastro-intestinal simptoms:  dysphagia, suppressed gag reflex.
 nausea,  Respiratory simptoms respiratory
 vomiting, failure.
 abdominal pain.
 Manifestations of the autonomic
dysfunction:
 Paralysis of cranial nerves III, IV, and  Dry mouth, dry throat
VI:
 Constipation
 blurred vision,
 Gastric dilatation
 diplopia,
 Urinary retention
 ptosis,
 Orthostatic hypotension
 extraocular muscle weakness
/paresis,  Reduced lacrimation
 fixed/dilated pupils,  Normal mental status
 Afebrile.
 Face in botulism

Suppressed gag reflex Fixed/dilated pupils

Infant botulism

 Constipation (95%)
 Absence of a gag reflex,
 Profound hypotonia,
 Hyporeflexia ,
 Feeding difficulties,
 Weakened cry,
 Ptosis,
 Hypotonia.
Wound botulism

 Incubation: 4-14 days.

 Neurological findings
(like food botulism)
without GI prodrome.
Lab tests
 Toxin identification:
 mouse neutralization bioassay from serum, stool,
vomitus, gastric aspirate, and suspected foods.
 cultures of food samples, gastric aspirates, or faecal
material.
 Wound cultures - grow C botulinum
 Electromyography (EMG) - reduced amplitude of
compound muscle action potentials.
Differential Diagnoses

 Acute poliomyelitis
 Guillain-Barré syndrome (Miller-Fisher variant)
 Lambert-Eaton syndrome
 Myasthenia gravis
 Aminoglycoside toxicity
 Tick paralysis
 Atropine poisoning
 Congenital myopathy
 Electrolyte imbalance
 Genetic metabolic disorders
Tratment: 1. Supportive care
 Nosocomial infections prophylaxis
 Deep venous thrombosis prophylaxis
 Stress ulcer prophylaxis
 Intubation and mechanical ventilation for:
 vital capacity is less than 30% of predicted,

 paralysis is progressing rapidly

 hypoxemia + hypercarbia
 Patients with
 bowel sounds
 cathartics and enemas (to remove unabsorbed botulinum toxin)
 +/-tube feeding
 ileus
 nasogastric suction
 intravenous hyperalimentation
 Foley catheter for bladder incontinence.
 2. Surgical Care

 Wound botulism
 incision / debridement of the infected wound.
 3. Medication

 Antibiotics – just in wound botulism:

 Penicillin G
 Chloramphenicol
 Clindamycin
 Botulinum antitoxin - essential in the treatment of botulism
 produced from horse serum – for foodborne, wound botulism
 Heptavalent botulinum antitoxin (A  G) (for infant botulism too)
 Bivalent botulinum antitoxin AB
 Monovalent botulinum antitoxin E

 produced from adult plasma (type A and B) – for infant botulism

 Human botulism immune globulin
Prevention
 Use proper canning techniques (121 C+
30 min).
 Prepare and store food safely
 Avoid giving honey to babies under the
age of 1 year.
 Correct treatment of the wounds
Bibliography
1. http://www.qiagen.com
2. http://bestpractice.bmj.com
3. http://bioweb.uwlax.edu
4. http://emedicine.com
5. Mandell's Principles and Practice of
Infectious Diseases, 5th edition, 2000
6. http://www.cdc.gov