Botulism

Adult Botulism

Background

• Clostridium botulinum produces toxin that blocks Ach release from presynaptic membrane
  • Ingestion of preformed heat-labile toxin
• Cases due to:
  • Improper (home) canning
  • Black-tar heroin use
  • Wound infection (contaminated wounds, C-section, tooth abscess, sinus infection)
• Symptoms begin 6-48 hr after exposure

Clinical Features

• GI
  • nausea and vomiting, abdominal cramps, diarrhea or constipation
  • Not seen in patients who contract botulism from heroin or contaminated wound
• Neuro
  • Vertigo is common
  • Symmetrical descending weakness leading to flaccid paralysis
  • Cranial nerves and bublar muscles are affected first: diplopia, dysarthria, dysphagia
  • Blurred vision and ptosis
  • Decreased deep tendon reflexes
    • Will progress to respiratory depression if not treated
• Anticholinergic signs
  • Decreased salivation: due to cholinergic fiber blockage
    • Dry mouth, painful tongue, sore throat
  • Urinary retention, dry skin/eyes, hyperthermia
• Dilated pupils (in contrast to patients with MG)

Infantile Botulism

Background

• Due to consumption of botulinum spores
  • Ingestion of honey, corn syrup, and vacuum/environmental dust
  • Higher GI tract pH of infants makes them more susceptible
• Most cases occur in <1 yr, 90% occur in <6 mo

Clinical Features

• Floppy Baby Syndrome
  • Loss of facial expression
  • Noticeable neck and peripheral weakness
• GI symptoms
  • Poor feeding
  • Constipation
  • Decreased suckling
• Other
  • Lethargy
  • Weak cry

Differential Diagnosis

Weakness

• Neuromuscular weakness
  • UMN:
    • CVA
    • Hemorrhagic stroke
    • Multiple sclerosis
    • Amyotrophic Lateral Sclerosis (ALS) (UMN & LMN)
  • Spinal cord disease:
    • Infection (Epidural abscess)
    • Infarction/ischemia
    • Trauma (Spinal Cord Syndromes)
    • Inflammation (Transverse Myelitis)
    • Degenerative (Spinal muscular atrophy)
    • Tumor
  • Peripheral nerve disease:
    • Guillain-Barre syndrome
    • Toxins (Ciguatera)
    • Tick paralysis
    • DM neuropathy (non-emergent)
  • NMJ disease:
    • Myasthenia gravis crisis
    • Botulism
    • Organophosphate toxicity
    • Lambert-Eaton myasthenic syndrome
  • Muscle disease:
    • Rhabdomyolysis
    • Dermatomyositis
    • Polymyositis
    • Alcoholic myopathy
• Non-neuromuscular weakness
  • Can't miss diagnoses:
    • ACS
    • Arrhythmia/Syncope
    • severe infection/Sepsis
    • Hypoglycemia
    • Periodic paralysis (electrolyte disturbance, K, Mg, Ca)
      • Hypokalemic periodic paralysis
      • Thyrotoxic periodic paralysis
    • Respiratory failure
  • Emergent Diagnoses:
    • Symptomatic Anemia
    • Severe dehydration
    • Hypothyroidism
    • Polypharmacy
    • Malignancy
  • Other causes of weakness and paralysis
    • Acute intermittent porphyria (ascending weakness)

Bioterrorism Agents

Category A

• Anthrax
• Smallpox
• Plague
• Tularemia
• Botulinum Toxin
• Viral hemorrhagic fever

Category B

• Ricin
• Brucellosis
• Epsilon toxin
• Psittacosis
• Q Fever
• Staph enterotoxin B
• Typhus
• Glanders
• Melioidosis
• Food safety threats
• Water safety threats
• Viral encephalitis

Category C

• Influenza
• Yellow fever
• Tickborne hemorrhagic fever
• Tickborne encephalitis

Management

Contact CDC Emergency Hotline 1-707-488-7100 for all suspected bioterrorism cases

Supportive Care

• Early ventilatory support
  • Consider intubation when vital capacity <30% predicted or <12cc/kg
• Wound Managment
  • Early wound debreedment with surgical consult.
  • Also exclude Necrotizing fasciitis and coverage with same broad antibiotic coverage

Foodborne Botulism

• Equine Serum Botulism Antitoxin
  • only for patients > 1yo
• Antitoxin obtained through CDC or local Department of Health.

Infant Botulism (<1yo)

• Human-based Botulism IG 100mg/kg IV x 1 dose (BabyBIG)
  • infusion divided into 25mg/kg/hr IV x 15 min followed by 50mg/kg/hr if no allergic reactions
  • Stop infusion after total of 100mg/kg infused
• BabyBIG obtained through CDC or local Department of Health

Inhalational Botulism

• Equine Serum Botulism Antitoxin
  • only for patients > 1yo
• Antitoxin obtained through CDC or local Department of Health

Wound Botulism

• Individualize therapy with ID consultant
• Broad antibiotic coverage same as for Necrotizing fasciitis while awaiting wound cultures

Disposition

• Admit to ICU
• Consider ID Consult

See Also

• Weakness
• Bioterrorism
• Clostridium

Authors

Jordan Swartz, Aaron Snyder, Ross Donaldson, Daniel Ostermayer, Michael Holtz, Joel Clinton Miller, Joe Carpenter, Neil Young