OVERVIEW
- endotoxins from Clostridium botulinum (and other Clostridia) -> prevents the release of Ach -> neuroparalytic disorder
- spore forming anaerobes with heat resistant spores
- found in soil and marine sediment
TYPES
- food-borne botulism
- wound botulism
- infant intestinal botulism
- adult intestinal botulism
- inhalational botulism
- iatrogenic botulism
CLINICAL FEATURES
(1) cranial neuropathies
(2) descending paralysis
(3) bilateral symptoms
(4) no fever
(5) clear sensorium
(6) lack of sensory findings
Food-borne
- toxin absorbed from small intestine
- home-canned fruit and vegetable ingestion
- symptoms within 12-36 hrs
- GI distress -> neuro symptoms
- parasympathetic dysfunction: dry mouth, blurred vision, dilated pupils, cardiovascular instability
- severity proportional to amount of endotoxin
Wound
- from in vivo toxin production in abscessed devitalised tissue
- 7 day incubation period
- no GI upset prodrome otherwise identical
Infant intestinal
- ingestion of spores -> colonise large intestine -> toxin production
- 2-4 months of life
- constipation, poor feeding, lethargy -> acute tetraparesis and respiratory failure
- hypotonia
- head lag
- ptosis
- reduced facial expression
- reduced suck and swallow
- loss of reflexes
- slowly improves after weeks
Adult intestinal
- intestinal colonisation -> when gastric barrier and intestinal flora altered -> endotoxin absorption
- surgery, gastric achlorhydria, broad spectrum antibiotics, IBD
Inhalational
- bioweapon
Iatrogenic
- used to treat: dystonia, spasticity, cosmesis
INVESTIGATIONS
- collect possible source + gastric, stool, serum samples
- mouse toxicity and neutralisation assay
- LP: rule out GBS
- edrophonium test: rule out MG
- EMG: normal nerve conduction, small motor response seen on repetitive nerve stimulation
MANAGEMENT
- notify public health
- antitoxin
- supportive
- IV human botulism globulin
- wound botulism: debride, penicillin
References and Links
Journal articles
- Chaudhry R. Botulism: a diagnostic challenge. Indian J Med Res. 2011 Jul;134:10-2. PubMed PMID: 21808127; PubMed Central PMCID: PMC3171901.
- Davis LE. Botulinum toxin. From poison to medicine. West J Med. 1993 Jan;158(1):25-9. Review. PubMed PMID: 8470380; PubMed Central PMCID: PMC1021932.
- Dhaked RK, Singh MK, Singh P, Gupta P. Botulinum toxin: bioweapon & magic drug. Indian J Med Res. 2010 Nov;132:489-503. Review. PubMed PMID: 21149997; PubMed Central PMCID: PMC3028942.
- Sam AH, Beynon HL. Images in clinical medicine: Wound botulism. N Engl J Med. 2010 Dec 16;363(25):2444. doi: 10.1056/NEJMicm1003352. PubMed PMID: 21158660. [Free Fulltext]
- Vossen MG, et al. The First Case(s) of Botulism in Vienna in 21 Years: A Case Report. Case Rep Infect Dis. 2012;2012:438989. doi: 10.1155/2012/438989. Epub 2012 Jun 21. PubMed PMID: 22779015; PubMed Central PMCID: PMC3388280.
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