Botulism: Difference between revisions

Revision as of 00:17, 24 April 2015

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 6-48hr after exposure

Clinical Features

GI
- N/V, abdominal cramps, diarrhea or constipation
- Not seen in pts 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 pts w/ 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 <6m

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)
    - Acute flaccid myelitis
  - Degenerative (Spinal muscular atrophy)
  - Tumor
- Peripheral nerve disease:
  - Guillain-Barre syndrome
  - Toxins (Ciguatera)
  - Tick paralysis
  - Diabetic peripheral neuropathy
- Neuromuscular junction disease:
- 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
  - Aortic disease - occlusion, stenosis, dissection
- Other causes of weakness and paralysis
  - Acute intermittent porphyria (ascending weakness)

Treatment

Ventilatory support
- Consider intubation when vital capacity <30% predicted or <12cc/kg
Adult: Antitoxin/immune globulin
Infant
- Supportive care only (no benefit from antitoxin or abx)
  - Consider IV Botulism Immune Globulin (BabyBIG)
Wound
- Antitoxin, wound irrigation & debridement
- PCN G 10-20 mil units/day

Disposition

Admit to ICU
Consider ID Consult

@@ Line 1: / Line 1: @@
 ==Adult Botulism==
 ===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 6-48hr after exposure
 ===Clinical Features===
-#GI
+*GI
-##N/V, abd cramps, diarrhea or constipation
+**N/V, abdominal cramps, diarrhea or constipation
-##Not seen in pts who contract botulism from heroin or contaminated wound
+**Not seen in pts 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 pts w/ MG)
 ==Infantile Botulism==
@@ Line 46: / Line 49: @@
 ==Treatment==
-#Ventilatory support
+*Ventilatory support
-##Consider intubation when VC <30% predicted or <12cc/kg
+**Consider intubation when vital capacity <30% predicted or <12cc/kg
-#Antitoxin/immune globulin
+*'''Adult''': Antitoxin/immune globulin
-#Infant
+*'''Infant'''
-##Supportive care only (no benefit from antitoxin or abx)
+**Supportive care only (no benefit from antitoxin or abx)
-###Consider human botulism immunoglobulin (BabyBIG)
+***Consider IV Botulism Immune Globulin (BabyBIG)
-#Wound
+*Wound
-##Antitoxin, wound irrigation & debridement, Pen G 10-20 mil units/day
+**Antitoxin, wound irrigation & debridement
+**PCN G 10-20 mil units/day
 ==Disposition==
-#Admit to ICU
+*Admit to ICU
+*Consider ID Consult
+==References==
+<references/>
 ==See Also==