Botulism

Adult Botulism

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

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)

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

Floppy Baby Syndrome
- Loss of facial expression
- Noticeable neck and peripheral weakness
GI symptoms
- Poor feeding
- Constipation
- Decreased suckling
Other
- Lethargy
- Weak cry

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)

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