Botulism

OVERVIEW

  • endotoxins from Clostridium botulinum (and other Clostridia) -> prevents the release of Ach -> neuroparalytic disorder
  • spore forming anaerobes with heat resistant spores
  • found in soil and marine sediment

TYPES

  • food-borne botulism
  • wound botulism
  • infant intestinal botulism
  • adult intestinal botulism
  • inhalational botulism
  • iatrogenic botulism

CLINICAL FEATURES

(1) cranial neuropathies
(2) descending paralysis
(3) bilateral symptoms
(4) no fever
(5) clear sensorium
(6) lack of sensory findings

Food-borne

  • toxin absorbed from small intestine
  • home-canned fruit and vegetable ingestion
  • symptoms within 12-36 hrs
  • GI distress -> neuro symptoms
  • parasympathetic dysfunction: dry mouth, blurred vision, dilated pupils, cardiovascular instability
  • severity proportional to amount of endotoxin

Wound

  • from in vivo toxin production in abscessed devitalised tissue
  • 7 day incubation period
  • no GI upset prodrome otherwise identical

Infant intestinal

  • ingestion of spores -> colonise large intestine -> toxin production
  • 2-4 months of life
  • constipation, poor feeding, lethargy -> acute tetraparesis and respiratory failure
  • hypotonia
  • head lag
  • ptosis
  • reduced facial expression
  • reduced suck and swallow
  • loss of reflexes
  • slowly improves after weeks

Adult intestinal

  • intestinal colonisation -> when gastric barrier and intestinal flora altered -> endotoxin absorption
  • surgery, gastric achlorhydria, broad spectrum antibiotics, IBD

Inhalational

  • bioweapon

Iatrogenic

  • used to treat: dystonia, spasticity, cosmesis

INVESTIGATIONS

  • collect possible source + gastric, stool, serum samples
  • mouse toxicity and neutralisation assay
  • LP: rule out GBS
  • edrophonium test: rule out MG
  • EMG: normal nerve conduction, small motor response seen on repetitive nerve stimulation

MANAGEMENT

  • notify public health
  • antitoxin
  • supportive
  • IV human botulism globulin
  • wound botulism: debride, penicillin

References and Links

Journal articles

  • Chaudhry R. Botulism: a diagnostic challenge. Indian J Med Res. 2011 Jul;134:10-2. PMC3171901.
  • Davis LE. Botulinum toxin. From poison to medicine. West J Med. 1993 Jan;158(1):25-9. PMC1021932.
  • Dhaked RK, Singh MK, Singh P, Gupta P. Botulinum toxin: bioweapon & magic drug. Indian J Med Res. 2010 Nov;132:489-503. PMC3028942.
  • Sam AH, Beynon HL. Images in clinical medicine: Wound botulism. N Engl J Med. 2010 Dec 16;363(25):2444. PMID: 21158660.
  • Vossen MG, et al. The First Case(s) of Botulism in Vienna in 21 Years: A Case Report. Case Rep Infect Dis. 2012;2012:438989. PMC3388280.

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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