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
CCC Neurocritical Care Series
Emergencies: Brain Herniation, Eclampsia, Elevated ICP, Status Epilepticus, Status Epilepticus in Paeds
DDx: Acute Non-Traumatic Weakness, Bulbar Dysfunction, Coma, Coma-like Syndromes, Delayed Awakening, Hearing Loss in ICU, ICU acquired Weakness, Post-Op Confusion, Pseudocoma, Pupillary Abnormalities
Neurology: Anti-NMDA Encephalitis, Basilar Artery Occlusion, Central Diabetes Insipidus, Cerebral Oedema, Cerebral Venous Sinus Thrombosis, Cervical (Carotid / Vertebral) Artery Dissections, Delirium, GBS vs CIP, GBS vs MG vs MND, Guillain-Barre Syndrome, Horner’s Syndrome, Hypoxic Brain Injury, Intracerebral Haemorrhage (ICH), Myasthenia Gravis, Non-convulsive Status Epilepticus, Post-Hypoxic Myoclonus, PRES, Stroke Thrombolysis, Transverse Myelitis, Watershed Infarcts, Wernicke’s Encephalopathy
Neurosurgery: Cerebral Salt Wasting, Decompressive Craniectomy, Decompressive Craniectomy for Malignant MCA Syndrome, Intracerebral Haemorrhage (ICH)
— SCI: Anatomy and Syndromes, Acute Traumatic Spinal Cord Injury, C-Spine Assessment, C-Spine Fractures, Spinal Cord Infarction, Syndomes,
— SAH: Acute management, Coiling vs Clipping, Complications, Grading Systems, Literature Summaries, ICU Management, Monitoring, Overview, Prognostication, Vasospasm
— TBI: Assessment, Base of skull fracture, Brain Impact Apnoea, Cerebral Perfusion Pressure (CPP), DI in TBI, Elevated ICP, Limitations of CT, Lund Concept, Management, Moderate Head Injury, Monitoring, Overview, Paediatric TBI, Polyuria incl. CSW, Prognosis, Seizures, Temperature
ID in NeuroCrit. Care: Aseptic Meningitis, Bacterial Meningitis, Botulism, Cryptococcosis, Encephalitis, HSV Encephalitis, Meningococcaemia, Spinal Epidural Abscess
Equipment/Investigations: BIS Monitoring, Codman ICP Monitor, Continuous EEG, CSF Analysis, CT Head, CT Head Interpretation, EEG, Extradural ICP Monitors, External Ventricular Drain (EVD), Evoked Potentials, Jugular Bulb Oxygen Saturation, MRI Head, MRI and the Critically Ill, Train of Four (TOF), Transcranial Doppler
Pharmacology: Desmopressin, Hypertonic Saline, Levetiracetam (Keppra), Mannitol, Midazolam, Sedation in ICU, Thiopentone
MISC: Brainstem Rules of 4, Cognitive Impairment in Critically Ill, Eye Movements in Coma, Examination of the Unconscious Patient, Glasgow Coma Scale (GCS), Hiccoughs, Myopathy vs Neuropathy, Neurology Literature Summaries, NSx Literature Summaries, Occulocephalic and occulovestibular reflexes, Prognosis after Cardiac Arrest, SIADH vs Cerebral Salt Wasting, Sleep in ICU
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.
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
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