Botulism: Difference between revisions

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==Background==
==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 | diplopia]], dysarthria, dysphagia, poor gag reflex
**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)


- sporeforming,m obligate anaerobe, gram positive
==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


- lethal dose 1 ng/kg
==Differential Diagnosis==
{{Weakness DDX}}


- 1 gm can kill 1 million people
{{Bioterrorism agents}}


- blocks release of Ach from presynaptic membrane
==Management==
'''Contact CDC Emergency Hotline 1-707-488-7100 for all suspected bioterrorism cases'''


- experimental vaccine
{{Botulism treatment}}
 
 
==Symptoms==
 
 
- symmetric, desc. paralysis w/B/L cranial nerve neuropathies (diplopia, dysarthria, ptosis)
 
- GI sxs: N/V, pain, late constipation
 
- Respiratory Failure
 
 
INFANT BOTULISM
 
- no honey or corn syrup to < 1 yo
 
- most cases < 1 y/o, 90% < 6mo
 
- most common form of botulism
 
- relative achlorhydia, poorly developed gut flora
 
- sxs from mild failure to thrive to sudden infant death
 
- drooling, ptosis, dilated/sluggish pupils, weak cry, feeding difficulties, constipation, resp arrest, poor head control, diminished muscle tone
 
 
WOUND BOTULISM
 
- black tar heroin, dirty wounds, C-section, tooth abscess, sinus infections
 
- incubation 10 days
 
- wound may appear benign
 
- GI sxs absent
 
 
==Diagnosis==
 
 
- clinically
 
- EMG studies: in botulism and Lambert-Eaton, few AcH released and muscle fibers don't reach threshold for contraction. With rapid nerve stim, can get enough AcH buildup in multiple muscle fibers to get "posttetanic facilitation."
 
- Nerve Conduction - normal in botulism (unlike GBS)
 
 
==DDx==
 
 
1. Myasthenia Gravis - EMG findings and antibody studies will differentiate (decremental response to repetitive nerve stimulation). CAN see false positive improvement to Tensilon test in botulism
 
2. Lambert-Eaton - spares resp muscles and primarily affects proximal lower limb muscles EMG findings similar to botulism (post-tetanic facilitation) but not identical
 
3. Guillain -Barre - Miller Fisher variant has prominent ataxia & areflexia that isn't seen in botulism. Nerve conduction tests are also abnormal
 
4. Poliomyelitis - usually have fever and asymmetric weakness. Ascending paralysis and CSF pleocytosis.
 
5. Tick Paralysis - ascending paralysis, abnl nerve cond tests
 
6. Diphtheria - proximal to distal spread of weakness 1-3 mo after fever and pharyngitis
 
7. Hyperthyroidism
 
8. Paralytic fish poisoning - tetrodotoxication (w/in 1 hr of fish eat)
 
9. Mg, mushroom or chemical (arsenic,thallium, anticholinergic) or meds (antichol, aminogly)
 
10. Sepsis
 
 
==Workup==
 
 
- Anaerobic cxs: emesis, gastric fluid, stool, food, wound, serum
 
- EPS - EMG shows decr amplitude with post-tetanic facilitation Nerve conduction normal
 
 
==Treatment==
 
 
- Ventilatory support: Intubate when VC < 30% predicted or < 12 cc/kg
 
- Foodbrone: antitoxin and AC, consider cathartics
 
- Infant: supportive care only, no benefit from antitoxin or Abx
 
- Wound: antitoxin, Td, wound irrigation & debridement even if appears well. Pen G 10-20 mill units/day.


==Disposition==
*Admit to ICU
*Consider ID Consult


==References==
<references/>


==See Also==
*[[Weakness]]
*[[Bioterrorism]]
*[[Clostridium]]


[[Category:ID]]
[[Category:ID]]
[[Category:Toxicology]]

Revision as of 01:56, 24 January 2021

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, poor gag reflex
    • 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

Bioterrorism Agents[1]

Category A

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

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

References

  1. ↑ https://www.niaid.nih.gov/topics/biodefenserelated/biodefense/pages/cata.aspx Accessed 02/26/16

See Also

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