2. Definition
Definition
Botulism is a paralytic disease
caused by potent protein neurotoxins
elaborated by clostridium botulinum.
Botulism is characterized by
symmetrical, descending, flaccid
paralysis of motor and autonomic
nerves usually beginning with cranial
nerves
3. Etiologic Agent
Etiologic Agent
C. botulinum is an anaerobic gram-
positive organism that form spors;
C. botulinum
C. botulinum is in soil and marine
environments throughout the world.
C. botulinum
C. botulinum elaborates the most
potent bacterial toxin.
4. – Spores
Spores
Ubiquitous
Ubiquitous
Resistant to heat, light, drying and radiation
Resistant to heat, light, drying and radiation
Spores may survive boiling for several hours
Spores may survive boiling for several hours
at 100
at 100 o
o
C
C
Specific conditions for germination
Specific conditions for germination
– Anaerobic conditions
Anaerobic conditions
– Warmth (10-50
Warmth (10-50o
o
C)
C)
– Mild alkalinity
Mild alkalinity
5. Neurotoxins
Neurotoxins
Seven different types: A through G
Seven different types: A through G
– Different types affect different species
Different types affect different species
– All cause flaccid paralysis
All cause flaccid paralysis
– Only a few nanograms can cause illness
Only a few nanograms can cause illness
– Binds neuromuscular junctions
Binds neuromuscular junctions
Toxin: Destroyed by boiling
Toxin: Destroyed by boiling
Spores: Higher temperatures to be
Spores: Higher temperatures to be
inactivated
inactivated
6. Neurotoxins
Neurotoxins
– toxins A, B, E and F cause illness in humans
toxins A, B, E and F cause illness in humans
– toxins C and D cause illness in birds and
toxins C and D cause illness in birds and
mammals
mammals
– toxin G has been associated with sudden death,
toxin G has been associated with sudden death,
but not with neuroparalytic illness, in a few
but not with neuroparalytic illness, in a few
patients in Switzerland.
patients in Switzerland.
– Toxin type A produces the most severe
Toxin type A produces the most severe
syndrome, with the greatest proportion of
syndrome, with the greatest proportion of
patients requiring mechanical ventilation. Toxin
patients requiring mechanical ventilation. Toxin
type B appears to cause milder disease than
type B appears to cause milder disease than
type A.
type A.
9. Epidemiology
Epidemiology
Foodborne botulism
Foodborne botulism
– caused by eating foods that contain
caused by eating foods that contain
botulism toxin
botulism toxin
Intestinal botulism
Intestinal botulism (infant and child/adult)
(infant and child/adult)
– caused by ingesting spores of the bacteria
caused by ingesting spores of the bacteria
which germinate and produce toxin in the
which germinate and produce toxin in the
intestines.
intestines.
Wound botulism
Wound botulism
– C. botulinum spores germinate in the
C. botulinum spores germinate in the
wound.
wound.
10. Epidemiology
Epidemiology
The highest incidence rate is reported from the
The highest incidence rate is reported from the
Republic of Georgia and Armenia, where illness is
Republic of Georgia and Armenia, where illness is
associated with risky home-canning practices.
associated with risky home-canning practices.
In the United States during 1990–2000, the median
In the United States during 1990–2000, the median
number of foodborne cases of botulism per year
number of foodborne cases of botulism per year
was 23 (range, 17–43).
was 23 (range, 17–43).
Since the early1990s, cases in the United States
Since the early1990s, cases in the United States
have occurred almost exclusively in injection drug
have occurred almost exclusively in injection drug
users.
users.
11. Pathogenesis
Pathogenesis
Toxin enters bloodstream from mucosal surface or
Toxin enters bloodstream from mucosal surface or
wound
wound
Binds to peripheral cholinergic nerve endings
Binds to peripheral cholinergic nerve endings
Inhibits release of acetylcholine, preventing
Inhibits release of acetylcholine, preventing
muscles from contracting
muscles from contracting
Symmetrical, descending paralysis occurs
Symmetrical, descending paralysis occurs
beginning with cranial nerves and progressing
beginning with cranial nerves and progressing
downward
downward
Can result from airway obstruction or paralysis of
Can result from airway obstruction or paralysis of
respiratory muscles
respiratory muscles
Secondary complications related to prolonged
Secondary complications related to prolonged
ventilatory support and intensive care
ventilatory support and intensive care
13. Food-borne botulism
Food-borne botulism
Incubation period
Incubation period -
- 18-36 h (depending
18-36 h (depending
on toxin dose can range from a few hours to
on toxin dose can range from a few hours to
several days).
several days).
Home-canned goods (foodborne)
Home-canned goods (foodborne)
– particularly low-acid foods such as
particularly low-acid foods such as
asparagus, beets, and corn
asparagus, beets, and corn
14. Nausea, vomiting, diarrhea
Nausea, vomiting, diarrhea
Diplopia, dysarthria, dysphonia,
Diplopia, dysarthria, dysphonia,
dysphagia
dysphagia
Descending weakness or paralysis
Descending weakness or paralysis
– Shoulders to arms to thighs to calves
Shoulders to arms to thighs to calves
Symmetrical flaccid paralysis
Symmetrical flaccid paralysis
No fever
No fever
Respiratory muscle paralysis
Respiratory muscle paralysis
15. Wound botulism
Wound botulism
Incubation period –
Incubation period – 10 days.
10 days.
Gastrointestinal symptoms are lacking
Gastrointestinal symptoms are lacking
Wound botulism has been documented:
Wound botulism has been documented:
After traumatic injury involving contamination with
After traumatic injury involving contamination with
soil;
soil;
After cesarean delivery
After cesarean delivery
After antibiotics have been given to prevent wound
After antibiotics have been given to prevent wound
infection.
infection.
(When present, fever is probably attributable to
(When present, fever is probably attributable to
concurrent infection with other bacteria).
concurrent infection with other bacteria).
16. Intestinal (infant)
Intestinal (infant)
botulism
botulism
May be one cause of sudden infant death.
May be one cause of sudden infant death.
Honey can contain
Honey can contain C. botulinum
C. botulinum spores
spores
– not recommended for infants <12 months old
not recommended for infants <12 months old
18. Diagnosis
Diagnosis
A diagnosis of botulism must be
A diagnosis of botulism must be
considered in patients with symmetric
considered in patients with symmetric
descending paralysis who are afebrile
descending paralysis who are afebrile
and mentally intact.
and mentally intact.
19. A 14-year-old with botulism. Note the weakness of his
A 14-year-old with botulism. Note the weakness of his
eye muscles and the drooping eyelids in the image to
eye muscles and the drooping eyelids in the image to
the left, and the large and non moving pupils in the
the left, and the large and non moving pupils in the
right image.
right image.
20. Laboratory diagnosis
Laboratory diagnosis
Toxin in serum, stool, gastric aspirate,
Toxin in serum, stool, gastric aspirate,
suspected food
suspected food
Culture of stool or gastric aspirate
Culture of stool or gastric aspirate
– Takes 5-7 days
Takes 5-7 days
Electromyography also diagnostic
Electromyography also diagnostic
Mouse neutralization test
Mouse neutralization test
– Results in 48 hours
Results in 48 hours
21. Laboratory diagnosis
Laboratory diagnosis
Botulinum toxin can be detected by a
Botulinum toxin can be detected by a
variety of techniques, including:
variety of techniques, including:
Enzyme-linked immunosorbent assays
Enzyme-linked immunosorbent assays
(ELISAs);
(ELISAs);
Electrochemiluminescent (ECL) tests
Electrochemiluminescent (ECL) tests
23. Treatment
Treatment
Persons of all ages (including infants) in whom
Persons of all ages (including infants) in whom
botulism is suspected should be hospitalized
botulism is suspected should be hospitalized
immediately in an intensive care setting, with
immediately in an intensive care setting, with
frequent monitoring of vital capacity and
frequent monitoring of vital capacity and
mechanical ventilation if required.
mechanical ventilation if required.
In adults, botulism can be treated by passive
In adults, botulism can be treated by passive
immunization with a horse-derived antitoxin,
immunization with a horse-derived antitoxin,
which blocks the action of the toxin circulating
which blocks the action of the toxin circulating
in the blood
in the blood
24. Treatment
Treatment
Intensive care immediately
Intensive care immediately
– Ventilator for respiratory failure
Ventilator for respiratory failure
Botulinum antitoxin
Botulinum antitoxin
– Derived from equine source
Derived from equine source
– CDC distributes
CDC distributes
– Used on a case-by-case basis
Used on a case-by-case basis
Botulism immune globulin
Botulism immune globulin
– Infant cases of types A and G
Infant cases of types A and G
25. Equine antitoxin
Equine antitoxin
– Trivalent and bivalent antitoxins available
Trivalent and bivalent antitoxins available
through the CDC
through the CDC
– Licensed trivalent antitoxin neutralizes type A,
Licensed trivalent antitoxin neutralizes type A,
B, and E botulism toxins
B, and E botulism toxins
– Effective in the treatment of foodborne,
Effective in the treatment of foodborne,
intestinal, and wound botulism
intestinal, and wound botulism
– Effectiveness for inhalation botulism has not
Effectiveness for inhalation botulism has not
been proven
been proven
– Does not reverse current paralysis, but may limit
Does not reverse current paralysis, but may limit
progression and prevent nerve damage if
progression and prevent nerve damage if
administered early
administered early
26. Hypersensitivity to equine antitoxin
Hypersensitivity to equine antitoxin
– 9% of people experience some hypersensitivity
9% of people experience some hypersensitivity
27. Botulism Vaccine
Botulism Vaccine
A toxoid vaccine (antigen types A, B,
A toxoid vaccine (antigen types A, B,
C, D, and E) is available for laboratory
C, D, and E) is available for laboratory
workers at high risk of exposure
workers at high risk of exposure
Limited supplies of this vaccine
Limited supplies of this vaccine
available
available
28. Therapeutic Uses of
Therapeutic Uses of
Botulism Toxin
Botulism Toxin
There is a vaccine for botulism that
There is a vaccine for botulism that
protects against type A, B, C, D, and E
protects against type A, B, C, D, and E
available for those at high risk of
available for those at high risk of
exposure. In the event of a bioterrorist
exposure. In the event of a bioterrorist
attack of botulism toxin, however,
attack of botulism toxin, however,
reserves would quickly be depleted.
reserves would quickly be depleted.
