Botulism

Adult Botulism

Background

1. Clostridium botulinum produces toxin that blocks Ach release from presynaptic membrane
2. Cases due to:
   1. Improper canning
   2. Black-tar heroin use
   3. Wound infection (contaminated wounds, C-section, tooth abscess, sinus infection)
3. Symptoms begin 6-48hr after exposure

Clinical Features

1. GI
   1. N/V, abd cramps, diarrhea or constipation
   2. Not seen in pts who contract botulism from heroin or contaminated wound
2. Neuro
   1. Vertigo is common
   2. Symmetrical descending weakness leading to paralysis
   3. Cranial nerves and bublar muscles are affected first: diplopia, dysarthria, dysphagia
      1. Will progress to respiratory depression if not treated
3. Anticholinergic signs
   1. Decreased salivation: due to cholinergic fiber blockage
      1. Dry mouth, painful tongue, sore throat
   2. Urinary retention, dry skin/eyes, hyperthermia
4. Dilated pupils (in contrast to pts w/ MG)

Infantile Botulism

Background

• Due to consumption of botulinum spores (usually from honey)
  • Higher GI tract pH of infants makes them more susceptible
• Most cases occur in <1yr, 90% occur in <6m

Clinical Features

1. GI
   1. Constipation
   2. Poor feeding
2. Lethargy
3. Weak cry
4. Floppy infant

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:
    • Myasthenia gravis crisis
    • Botulism
    • Organophosphate toxicity
    • Lambert-Eaton myasthenic syndrome
  • 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

1. Ventilatory support
   1. Consider intubation when VC <30% predicted or <12cc/kg
2. Antitoxin/immune globulin
3. Infant
   1. Supportive care only (no benefit from antitoxin or abx)
      1. Consider human botulism immunoglobulin (BabyBIG)
4. Wound
   1. Antitoxin, wound irrigation & debridement, Pen G 10-20 mil units/day

Disposition

1. Admit to ICU

See Also

• Weakness
• Bioterrorism
• Clostridium