Botulism: Difference between revisions
 
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==Background==
==Adult Botulism==
# sporeforming,m obligate anaerobe, gram positive
===Background===
# lethal dose 1 ng/kg
*''Clostridium botulinum'' produces toxin that blocks Ach release from presynaptic membrane
# 1 gm can kill 1 million people
**Ingestion of preformed heat-labile toxin
# blocks release of Ach from presynaptic membrane
*Cases due to:
# experimental vaccine
**Improper (home) canning
**Black-tar heroin use
**Wound infection (contaminated wounds, C-section, tooth abscess, sinus infection)
*Symptoms begin 6-48 hr after exposure


==Symptoms==
===Clinical Features===
# symmetric, desc. paralysis w/B/L cranial nerve neuropathies (diplopia, dysarthria, ptosis)
[[File:Botulism1and2.png|thumb|A fully conscious patient with botulism causing weakness of the eye muscles and the drooping eyelids (left) and dilated and non-reactive pupils (right).]]
# GI sxs: N/V, pain, late constipation
[[File:PMC3223485 eplasty11e47 fig5.png|thumb|Six-week-old infant with botulism, demonstrating marked loss of muscle tone especially in the head and neck.]]
# Respiratory Failure
[[File:Infant botulism patient.jpeg|thumb|Infant botulismː despite not being asleep or sedated, he cannot open his eyes or move; he also has a weak cry.]]
*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)


===Infant Botulism===
==Infantile Botulism==
# no honey or corn syrup to < 1 yo
===Background===
# most cases < 1 y/o, 90% < 6mo
*Due to consumption of botulinum spores
# most common form of botulism
**Ingestion of honey, corn syrup, and vacuum/environmental dust
# relative achlorhydia, poorly developed gut flora
**Higher GI tract pH of infants makes them more susceptible
# sxs from mild failure to thrive to sudden infant death
*Most cases occur in <1 yr, 90% occur in <6 mo
# drooling, ptosis, dilated/sluggish pupils, weak cry, feeding difficulties, constipation, resp arrest, poor head control, diminished muscle tone


===Wound Botulism===
===Clinical Features===
# black tar heroin, dirty wounds, C-section, tooth abscess, sinus infections
*Floppy Baby Syndrome
# incubation 10 days
**Loss of facial expression
# wound may appear benign
**Noticeable neck and peripheral weakness
# GI sxs absent
*GI symptoms
**Poor feeding
**Constipation
**Decreased suckling
*Other
**Lethargy
**Weak cry


==Diagnosis==
==Differential Diagnosis==
# clinically
{{Weakness DDX}}
# 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==
{{Bioterrorism agents}}
# 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
# Lambert-Eaton - spares resp muscles and primarily affects proximal lower limb muscles EMG findings similar to botulism (post-tetanic facilitation) but not identical
# Guillain -Barre - Miller Fisher variant has prominent ataxia & areflexia that isn't seen in botulism. Nerve conduction tests are also abnormal
# Poliomyelitis - usually have fever and asymmetric weakness. Ascending paralysis and CSF pleocytosis.
# Tick Paralysis - ascending paralysis, abnl nerve cond tests
# Diphtheria - proximal to distal spread of weakness 1-3 mo after fever and pharyngitis
# Hyperthyroidism
# Paralytic fish poisoning - tetrodotoxication (w/in 1 hr of fish eat)
# Mg, mushroom or chemical (arsenic,thallium, anticholinergic) or meds (antichol, aminogly)
# Sepsis


==Workup==
==Management==
# Anaerobic cxs: emesis, gastric fluid, stool, food, wound, serum
'''Contact CDC Emergency Hotline 1-770-488-7100 for all suspected bioterrorism cases'''
# EPS - EMG shows decr amplitude with post-tetanic facilitation Nerve conduction normal


==Treatment==
{{Botulism treatment}}
# Ventilatory support: Intubate when VC < 30% predicted or < 12 cc/kg
 
# Foodbrone: antitoxin and AC, consider cathartics
==Disposition==
# Infant: supportive care only, no benefit from antitoxin or Abx
*Admit to ICU
# Wound: antitoxin, Td, wound irrigation & debridement even if appears well. Pen G 10-20 mill units/day
*Consider ID Consult
 
==References==
<references/>
 
==See Also==
*[[Weakness]]
*[[Bioterrorism]]
*[[Clostridium]]


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

Latest revision as of 16:35, 7 September 2022

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

A fully conscious patient with botulism causing weakness of the eye muscles and the drooping eyelids (left) and dilated and non-reactive pupils (right).
Six-week-old infant with botulism, demonstrating marked loss of muscle tone especially in the head and neck.
Infant botulismː despite not being asleep or sedated, he cannot open his eyes or move; he also has a weak cry.
  • 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 1-770-488-7100 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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