Botulism

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.