Botulism

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Overview

Botulism Microchapters
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Patient Information
Overview
Historical Perspective
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Pathophysiology
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Differentiating Botulism from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
History and Symptoms
Physical Examination
Laboratory Findings
CT
MRI
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Case #1
Botulism On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Botulism All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Botulism
CDC on Botulism
Botulism in the news
Blogs on Botulism
Directions to Hospitals Treating Botulism
Risk calculators and risk factors for Botulism

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Michael Maddaleni, B.S.

Overview

Botulism (Latin, botulus, sausage) is a rare, but serious paralytic illness caused by a nerve toxin, botulin, that is produced by the bacterium Clostridium botulinum. Botulinic toxin is one of the most powerful known toxins: about one microgram is lethal to humans. It acts by blocking nerve function and leads to respiratory and musculoskeletal paralysis. Botulism is an acute paralytic illness caused by a neurotoxin produced by Clostridium botulinum. Supportive care, including intensive care, is key but the role of other medical treatments is unclear. Botulism is an acute paralytic rare illness with a high mortality rate. It is caused by the action of bacterium Clostridium botulinum neurotoxin. yet there is no known medical treatment for it. Supportive care, including intensive care, is the best treatment for now.

Historical perspective

Clostridium botulinum botulism was named In 1870 by Muller (German physician). In 1895 Clostridium botulinum was first isolated by Emile Van Ermengem and It was in 1949 when Burgen's group discovered that botulinum toxin blocks neuromuscular transmission.

Classification

Botulism can be classified into foodborne, wound and infant botulism. Iatrogenic botulism and adult intestinal toxemia are rare types of botulism. They are differed from each other according to the mode of infection and the clinical presentation.

Pathophysiology

Botulism is most commonly caused by neurotoxins produced by C. botulinum. but C. baratii produces similar neurotoxins (5, 6). The neurotoxins which cause botulism are the most potent toxins currently known and cause paralysis through the inhibition of acetlylcholine release in human nerve endings. Clostridium botulinum is an obligate anaerobe that forms spores.

Causes

Clostridium botulinum is found in soil and untreated water throughout the world. It produces spores that survive in improperly preserved or canned food, where they produce toxin. When eaten, even tiny amounts of this toxin can lead to severe poisoning. The foods most commonly contaminated are home-canned vegetables, cured pork and ham, smoked or raw fish, and honey or corn syrup. Botulism may also occur if the organism enters open wounds and produces toxin there. Infant botulism occurs when living bacteria or its spores are eaten and grow within the baby's gastrointestinal tract. The most common cause of infant botulism is eating honey or corn syrup. Clostridium botulinum also occurs normally in the stool of some infants.

It has also been speculated that it is possible to acquire botulism through inhalation. So far, the only human cases of this occurring have been due to factory workers inadvertently inhaling it. It has been suspected that the botulinun toxin could be aerosolized into a weapon for use in a bioterrorist attack.

Differentiating botulism from other diseases

Botulism must be differentiated from neuromuscular disorders, neurotoxins, infections, and vascular diseases that present with muscle weakness, hypotonia, and flaccidity.

Epidemiology and demographics

Globally, botulism is fairly rare. In the United States, for example, an average of 110 cases are reported each year. Of these, roughly 70% are infant botulism, 25% are foodborne botulism, and 5% are wound botulism. The number of cases of food borne and infant botulism has changed little in recent years, but wound botulism has increased because of the use of black tar heroin, especially in California. Wound botulism may be caused even by inhaled cocaine.

Risk Factors

Botulism risk factors can be based upon the different types of the disease. The infants are more vulnerable to get infected with botulinum toxin. Honey and corn ingestion are common risk factors for the infants to get infected. Ingestion of preformed food and canned food increase the susceptibility of the infection. The intravenous drug abusers are vulnerable to get infected with wound botulism as well.

Screening

According to the United States Preventive Services Task Force (USPSTF), there are no screening recommendations for botulism.

Natural history, complications and prognosis

If botulism left untreated it may cause respiratory failure and even death. Common complications of botulism include, respiratory failure, difficult swallowing, speech difficulties, fatigue, and death. Botulism's prognosis depends on the amount of the ingested toxins and prompt treatment.

Diagnosis

History and symptoms

Botulism symptoms ranges from mild to very severe in some cases. The common symptoms generally are nausea, vomiting, diarrhea and dysphagia. The common symptoms in adult are double vision, blurred vision and slurred speech. The common in the infants constipation and weak crying. Botulism affects mainly the nervous system and may lead to paralysis.

Physical examination

Botulism physical examination is very important in order to suggest or exclude the disease. The patients with botulism appear dizzy and tired. The following signs are observed in the botulism patients: eyelid dropping, weakness of tongue muscle, nystagmus and decreased gag reflex. Paralytic ileus also may present. Botulism presentation shows many neurological manifestations like: generalized muscle weakness, abscent tendon reflexes, facial nerve impairment and speech impairment.

Laboratory Findings

Clinical diagnosis of botulism is confirmed by specialized laboratory testing that often requires days to complete. Routine laboratory test results are usually unremarkable. Therefore, clinical diagnosis is the foundation for early recognition of and response to a bioterrorist attack with botulinum toxin, and all treatment and management decisions should be made based on clinical diagnosis.

CT

There are no CT findings associated with botulism.

MRI

There are no MRI findings associated with botulism.

Other Diagnostic Studies

There are no other diagnostic findings associated with botulism.

Treatment

Medical Therapy

The mainstay of therapy for botulism is antitoxin therapy. Antimicrobial therapy is recommended for wound botulism after antitoxin has been administered. Breathing requires the use of many muscles, inluding the diaphragm. Therefore, botulism will make breathing very difficult and interventions to aid in the breathing process will be essential. Many people with botulism will need to be on a mechanical ventilator for a significant period of time. There are also other therapies such as antitoxin treatment. This method is not readily used on infants because of adverse side effects.

Surgery

Surgical intervention is not recommended in the treatment of botulism.

Primary Prevention

Secondary Prevention

After someone has been exposed to the clostridium botulinum bacteria, there needs to be ways to stop it from spreading and eventually causing damage to the host. This can be done through different techniques such as administering antitoxin and decontaminating suspected food sources.

Cost-Effectiveness of Therapy

Since there are only a few major treatments for Botulism, the financial aspect of the treatment will be relatively straight forward. The financial costs will revolve around things such as a prolonged hospital stay as well as antitoxin therapy. It should also be noted that cosmetic Botox will be at a different cost.

Future or Investigational Therapies

Classically, the treatment for botulism has been to deliver an antitoxin to the patient once exposed. Also, putting the patient on a mechanical ventilator has been a successful treatment method because patients with botulism have extreme trouble breathing on their own. Even though these treatments have been successful, there have been tests on a new drug that will block potassium channels in order to restore neuromuscular function after botulinum intoxication.

References

Historical Perspective

Botulism Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Botulism from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
History and Symptoms
Physical Examination
Laboratory Findings
CT
MRI
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Case #1
Botulism On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Botulism All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Botulism
CDC on Botulism
Botulism in the news
Blogs on Botulism
Directions to Hospitals Treating Botulism
Risk calculators and risk factors for Botulism

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]; Associate Editor(s)-in-Chief: Michael Maddaleni, B.S.

Overview

Clostridium botulinum botulism was named In 1870 by Muller (German physician). In 1895 Clostridium botulinum was first isolated by Emile Van Ermengem and It was in 1949 when Burgen's group discovered that botulinum toxin blocks neuromuscular transmission.

Historical Perspective

Food-borne botulism may be one of the first illnesses that has accompanied mankind since its beginning. The documents containing historical soureces and perspective on food poisoning before the 19th century have not been found yet. As there are some ancient dietary laws and taboos, some knowledge about the life-threatening consumption of poisoned foods may be reflected by them. One example of such a dietary taboo is the 10th century edict of Emperor Leo VI of Byzantium in which manufacturing of blood sausages was forbidden. There are also ancient case reports on intoxications with Atropa belladonna that seems like symptoms of patients with food-borne botulism, because the combination of dilated pupils and fatal muscle paralysis cannot be attributed to an atropine intoxication, although it was different they didn't think about it as a new disease. At the end of the 18th century, some well-documented outbreaks of “sausage poisoning” in Southern Germany, especially in Württemberg, led to early systematic botulinum toxin research. The first accurate and complete description of the clinical symptoms of food-borne botulism was published between 1817 and 1822 by the German physician and poet Justinus Kerner (1786–1862). He called the toxin as “sausage poison” or "Canadian bacon pathogen". He also developed the idea of a possible therapeutic use of botulinum toxin. Kerner’s had an amazing scientific approach to the problems of food poisoning during the period of enlightenment: after describing and categorizing empirical phenomena, he started animal experiments and clinical experiments on himself, developed hypotheses on the pathophysiology of the toxin, suggested measures for prevention and treatment of botulism, and, finally, developed visions and ideas about future perspectives regarding the toxin, including the idea of its therapeutic use. Although his amazing work, Kerner did not succeed in defining the suspected biological poison. Eighty years after Kerner's work, in 1895, a botulism outbreak after a funeral dinner with smoked ham in the small Belgian village of Ellezelles led to the discovery of the pathogen Clostridium botulinum by Emile Pierre van Ermengem, Professor of bacteriology at the University of Ghent. The bacterium was so called because of its pathological association with the sausages (Latin word for sausage = “botulus”) and although its shape is truely like a sausage, the reason they call ii is not associated with its microscopic shape. Modern botulinum toxin treatment which is known as chemodenervation therapy was pioneered by Alan B. Scott and Edward J Schantz in 1973 with monkey experiments and in 1980 with human applications.

United States

All data regarding botulism antitoxin releases and laboratory confirmation of cases in the US are recorded annually by the Centers for Disease Control and Prevention and published on their website.

• 1971 Bon Vivant botulism case On July 2, 1971, the U.S. Food and Drug Administration (FDA) released a public warning after learning that a New York man had died and his wife had become seriously ill due to botulism after eating a can of Bon Vivant vichyssoise soup.

• Between March 31 and April 6, 1977, 59 individuals developed type B botulism. All ill persons had eaten at the same Mexican restaurant in Pontiac, Michigan and all had consumed a hot sauce made with improperly home-canned jalapeño peppers, either by adding it to their food, or by eating a nacho that had had hot sauce used in its preparation. The full clinical spectrum (mild symptomatology with neurologic findings through life-threatening ventilatory paralysis) of type B botulism was documented.

• In April 1994, the largest outbreak of botulism in the United States since 1978 occurred in El Paso, Texas. Thirty persons were affected; 4 required mechanical ventilation. All ate food from a Greek restaurant. The attack rate among persons who ate a potato-based dip was 86% (19/22) compared with 6% (11/176) among persons who did not eat the dip (relative risk [RR] Å 13.8; 95% confidence interval [CI], 7.6–25.1). The attack rate among persons who ate an eggplant-based dip was 67% (6/9) compared with 13% (24/189) among persons who did not (RR Å 5.2; 95% CI, 2.9–9.5). Botulism toxin type A was detected from patients and in both dips. Toxin formation resulted from holding aluminum foil-wrapped baked potatoes at room temperature, apparently for several days, before they were used in the dips. Food handlers should be informed of the potential hazards caused by holding foil-wrapped potatoes at ambient temperatures after cooking.

• Beginning in late June 2007, 8 people contracted botulism poisoning by eating canned food products produced by Castleberry's Food Company in its Augusta, Georgia plant. It was later identified that the Castleberry's plant had serious production problems on a specific line of retorts that had under-processed the cans of food. These issues included broken cooking alarms, leaking water valves and inaccurate temperature devices, all the result of poor management of the company. All of the victims were hospitalized and placed on mechanical ventilation. The Castleberry's Food Company outbreak was the first instance of botulism in commercial canned foods in the United States in over 30 years.

• One person died, 21 cases were confirmed, and 10 more were suspected in Lancaster, Ohio when a botulism outbreak occurred after a church potluck in April 2015. The suspected source was a salad made from home-canned potatoes.

United Kingdom

The largest recorded outbreak of foodborne botulism in the United Kingdom occurred in June 1989. A total of 27 patients were affected; one patient died. Twenty-five of the patients had eaten one brand of hazelnut yogurt in the week before the onset of symptoms. This yogurt contained hazelnut conserve sweetened with aspartame rather than sugar. Control measures included the cessation of all yogurt production by the implicated producer, the withdrawal of the firm's yogurts from sale, the recall of cans of the hazelnut conserve, and advice to the general public to avoid the consumption of all hazelnut yogurts.

Botulinum Toxin as a Therapy

By 1973, Alan B Scott, MD, of Smith-Kettlewell Institute used botulinum toxin type A (BTX-A) in monkey experiments, and, in 1980, he officially used BTX-A for the first time in humans to treat strabismus. In December 1989, BTX-A (BOTOX) was approved by the US Food and Drug Administration (FDA) for the treatment of strabismus, blepharospasm, and hemifacial spasm in patients over 12 years old. The cosmetic effect of BTX-A was initially described by ophthalmologist Jean Carruthers and dermatologist Alastair Carruthers, a husband-and-wife team working in Vancouver, Canada, although the effect had been observed by a number of independent groups. On April 15, 2002, the FDA announced the approval of botulinum toxin type A (BOTOX Cosmetic) to temporarily improve the appearance of moderate-to-severe frown lines between the eyebrows (glabellar lines). BTX-A has also been approved for the treatment of excessive underarm sweating. Botulinum Toxin Type B (BTX-B) received FDA approval for treatment of cervical dystonia on December 21, 2000. Trade names for BTX-B are Myobloc in the United States, and Neurobloc® in the European Union.The acceptance of BTX-A use for the treatment of spasticity and muscle pain disorders is growing, with approvals pending in many European countries and studies on headaches (including migraine), prostatic symptoms, asthma, obesity and many other possible indications are ongoing.

Botox is manufactured by Allergan Inc (U.S.) for both therapeutic as well as cosmetic use. The formulation is best stored at cold temperature of 2-8 degrees Celsius. Dysport is a therapeutic formulation of the type A toxin developed and manufactured in the UK and which is licensed for the treatment of focal dystonias, symptoms of cerebral palsy, and certain cosmetic uses in many territories world wide.

References

Template:WikiDoc Sources

Pathophysiology

Botulism Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Botulism from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
History and Symptoms
Physical Examination
Laboratory Findings
CT
MRI
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Case #1
Botulism On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Botulism All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Botulism
CDC on Botulism
Botulism in the news
Blogs on Botulism
Directions to Hospitals Treating Botulism
Risk calculators and risk factors for Botulism

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3]; Associate Editor(s)-in-Chief: Michael Maddaleni, B.S.

Overview

Clostridium botulinum botulism was named In 1870 by Muller (German physician). In 1895 Clostridium botulinum was first isolated by Emile Van Ermengem and It was in 1949 when Burgen's group discovered that botulinum toxin blocks neuromuscular transmission.

Historical Perspective

Food-borne botulism may be one of the first illnesses that has accompanied mankind since its beginning. The documents containing historical soureces and perspective on food poisoning before the 19th century have not been found yet. As there are some ancient dietary laws and taboos, some knowledge about the life-threatening consumption of poisoned foods may be reflected by them. One example of such a dietary taboo is the 10th century edict of Emperor Leo VI of Byzantium in which manufacturing of blood sausages was forbidden. There are also ancient case reports on intoxications with Atropa belladonna that seems like symptoms of patients with food-borne botulism, because the combination of dilated pupils and fatal muscle paralysis cannot be attributed to an atropine intoxication, although it was different they didn't think about it as a new disease. At the end of the 18th century, some well-documented outbreaks of “sausage poisoning” in Southern Germany, especially in Württemberg, led to early systematic botulinum toxin research. The first accurate and complete description of the clinical symptoms of food-borne botulism was published between 1817 and 1822 by the German physician and poet Justinus Kerner (1786–1862). He called the toxin as “sausage poison” or "Canadian bacon pathogen". He also developed the idea of a possible therapeutic use of botulinum toxin. Kerner’s had an amazing scientific approach to the problems of food poisoning during the period of enlightenment: after describing and categorizing empirical phenomena, he started animal experiments and clinical experiments on himself, developed hypotheses on the pathophysiology of the toxin, suggested measures for prevention and treatment of botulism, and, finally, developed visions and ideas about future perspectives regarding the toxin, including the idea of its therapeutic use. Although his amazing work, Kerner did not succeed in defining the suspected biological poison. Eighty years after Kerner's work, in 1895, a botulism outbreak after a funeral dinner with smoked ham in the small Belgian village of Ellezelles led to the discovery of the pathogen Clostridium botulinum by Emile Pierre van Ermengem, Professor of bacteriology at the University of Ghent. The bacterium was so called because of its pathological association with the sausages (Latin word for sausage = “botulus”) and although its shape is truely like a sausage, the reason they call ii is not associated with its microscopic shape. Modern botulinum toxin treatment which is known as chemodenervation therapy was pioneered by Alan B. Scott and Edward J Schantz in 1973 with monkey experiments and in 1980 with human applications.

United States

All data regarding botulism antitoxin releases and laboratory confirmation of cases in the US are recorded annually by the Centers for Disease Control and Prevention and published on their website.

• 1971 Bon Vivant botulism case On July 2, 1971, the U.S. Food and Drug Administration (FDA) released a public warning after learning that a New York man had died and his wife had become seriously ill due to botulism after eating a can of Bon Vivant vichyssoise soup.

• Between March 31 and April 6, 1977, 59 individuals developed type B botulism. All ill persons had eaten at the same Mexican restaurant in Pontiac, Michigan and all had consumed a hot sauce made with improperly home-canned jalapeño peppers, either by adding it to their food, or by eating a nacho that had had hot sauce used in its preparation. The full clinical spectrum (mild symptomatology with neurologic findings through life-threatening ventilatory paralysis) of type B botulism was documented.

• In April 1994, the largest outbreak of botulism in the United States since 1978 occurred in El Paso, Texas. Thirty persons were affected; 4 required mechanical ventilation. All ate food from a Greek restaurant. The attack rate among persons who ate a potato-based dip was 86% (19/22) compared with 6% (11/176) among persons who did not eat the dip (relative risk [RR] Å 13.8; 95% confidence interval [CI], 7.6–25.1). The attack rate among persons who ate an eggplant-based dip was 67% (6/9) compared with 13% (24/189) among persons who did not (RR Å 5.2; 95% CI, 2.9–9.5). Botulism toxin type A was detected from patients and in both dips. Toxin formation resulted from holding aluminum foil-wrapped baked potatoes at room temperature, apparently for several days, before they were used in the dips. Food handlers should be informed of the potential hazards caused by holding foil-wrapped potatoes at ambient temperatures after cooking.

• Beginning in late June 2007, 8 people contracted botulism poisoning by eating canned food products produced by Castleberry's Food Company in its Augusta, Georgia plant. It was later identified that the Castleberry's plant had serious production problems on a specific line of retorts that had under-processed the cans of food. These issues included broken cooking alarms, leaking water valves and inaccurate temperature devices, all the result of poor management of the company. All of the victims were hospitalized and placed on mechanical ventilation. The Castleberry's Food Company outbreak was the first instance of botulism in commercial canned foods in the United States in over 30 years.

• One person died, 21 cases were confirmed, and 10 more were suspected in Lancaster, Ohio when a botulism outbreak occurred after a church potluck in April 2015. The suspected source was a salad made from home-canned potatoes.

United Kingdom

The largest recorded outbreak of foodborne botulism in the United Kingdom occurred in June 1989. A total of 27 patients were affected; one patient died. Twenty-five of the patients had eaten one brand of hazelnut yogurt in the week before the onset of symptoms. This yogurt contained hazelnut conserve sweetened with aspartame rather than sugar. Control measures included the cessation of all yogurt production by the implicated producer, the withdrawal of the firm's yogurts from sale, the recall of cans of the hazelnut conserve, and advice to the general public to avoid the consumption of all hazelnut yogurts.

Botulinum Toxin as a Therapy

By 1973, Alan B Scott, MD, of Smith-Kettlewell Institute used botulinum toxin type A (BTX-A) in monkey experiments, and, in 1980, he officially used BTX-A for the first time in humans to treat strabismus. In December 1989, BTX-A (BOTOX) was approved by the US Food and Drug Administration (FDA) for the treatment of strabismus, blepharospasm, and hemifacial spasm in patients over 12 years old. The cosmetic effect of BTX-A was initially described by ophthalmologist Jean Carruthers and dermatologist Alastair Carruthers, a husband-and-wife team working in Vancouver, Canada, although the effect had been observed by a number of independent groups. On April 15, 2002, the FDA announced the approval of botulinum toxin type A (BOTOX Cosmetic) to temporarily improve the appearance of moderate-to-severe frown lines between the eyebrows (glabellar lines). BTX-A has also been approved for the treatment of excessive underarm sweating. Botulinum Toxin Type B (BTX-B) received FDA approval for treatment of cervical dystonia on December 21, 2000. Trade names for BTX-B are Myobloc in the United States, and Neurobloc® in the European Union.The acceptance of BTX-A use for the treatment of spasticity and muscle pain disorders is growing, with approvals pending in many European countries and studies on headaches (including migraine), prostatic symptoms, asthma, obesity and many other possible indications are ongoing.

Botox is manufactured by Allergan Inc (U.S.) for both therapeutic as well as cosmetic use. The formulation is best stored at cold temperature of 2-8 degrees Celsius. Dysport is a therapeutic formulation of the type A toxin developed and manufactured in the UK and which is licensed for the treatment of focal dystonias, symptoms of cerebral palsy, and certain cosmetic uses in many territories world wide.

References

Template:WikiDoc Sources

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Natural History, Complications & Prognosis

Diagnosis

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Treatment

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