Botulism: Difference between revisions
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===Clinical Features=== | ===Clinical Features=== | ||
[[Botulism1and2|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).]] | [[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).]] | ||
[[File:PMC3223485 eplasty11e47 fig5.png|thumb|Six-week-old infant with botulism, demonstrating marked loss of muscle tone especially in the head and neck.]] | |||
[[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.]] | [[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 | *GI | ||
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[[Category:ID]] | [[Category:ID]] | ||
[[Category:Toxicology]] | [[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
- 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
- Decreased salivation: due to cholinergic fiber blockage
- 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
- Upper motor neuron:
- CVA
- Hemorrhagic stroke
- Multiple sclerosis
- Amyotrophic Lateral Sclerosis (ALS) (upper and lower motor neuron)
- Lower motor neuron:
- Spinal and bulbar muscular atrophy (Kennedy's syndrome)
- Spinal cord disease:
- Infection (Epidural abscess)
- Infarction/ischemia
- Trauma (Spinal Cord Syndromes)
- Inflammation (Transverse Myelitis)
- Degenerative (Spinal muscular atrophy)
- Tumor
- Peripheral nerve disease:
- Neuromuscular junction disease:
- Muscle disease:
- Rhabdomyolysis
- Dermatomyositis
- Polymyositis
- Alcoholic myopathy
- Upper motor neuron:
- Non-neuromuscular weakness
- Can't miss diagnoses:
- ACS
- Arrhythmia/Syncope
- Severe infection/Sepsis
- Hypoglycemia
- Periodic paralysis (electrolyte disturbance, K, Mg, Ca)
- Respiratory failure
- Emergent Diagnoses:
- Symptomatic Anemia
- Severe dehydration
- Hypothyroidism
- Polypharmacy
- Malignancy
- Aortic disease - occlusion, stenosis, dissection
- Other causes of weakness and paralysis
- Acute intermittent porphyria (ascending weakness)
- Can't miss diagnoses:
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
- Influenza
- Yellow fever
- Tickborne hemorrhagic fever
- Tickborne encephalitis
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