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


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


==Infantile Botulism==
==Infantile Botulism==
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**Ingestion of honey, corn syrup, and vacuum/environmental dust
**Ingestion of honey, corn syrup, and vacuum/environmental dust
**Higher GI tract pH of infants makes them more susceptible
**Higher GI tract pH of infants makes them more susceptible
*Most cases occur in <1 yr, 90% occur in <6m
*Most cases occur in <1 yr, 90% occur in <6 mo


===Clinical Features===
===Clinical Features===
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{{Weakness DDX}}
{{Weakness DDX}}


==Treatment==
{{Bioterrorism agents}}
#Ventilatory support
 
##Consider intubation when VC <30% predicted or <12cc/kg
==Management==
#Antitoxin/immune globulin
'''Contact CDC Emergency Hotline 1-707-488-7100 for all suspected bioterrorism cases'''
#Infant
 
##Supportive care only (no benefit from antitoxin or abx)
{{Botulism treatment}}
###Consider human botulism immunoglobulin (BabyBIG)
#Wound
##Antitoxin, wound irrigation & debridement, Pen G 10-20 mil units/day


==Disposition==
==Disposition==
#Admit to ICU
*Admit to ICU
*Consider ID Consult
 
==References==
<references/>


==See Also==
==See Also==
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[[Category:ID]]
[[Category:ID]]
[[Category:tox]]
[[Category:Toxicology]]

Revision as of 03:12, 15 July 2016

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

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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