Chapter 134. Botulism (Part 4)

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Botulism: Treatment Patients should be hospitalized and monitored closely, both clinically and by spirometry, pulse oximetry, and measurement of arterial blood gases for incipient respiratory failure. Intubation and mechanical ventilation should be strongly considered when the vital capacity is

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Chapter 134. Botulism (Part 4) Botulism: Treatment Patients should be hospitalized and monitored closely, both clinically and by spirometry, pulse oximetry, and measurement of arterial blood gases for incipient respiratory failure. Intubation and mechanical ventilation should be
strongly considered when the vital capacity is
cathartics and enemas may be used to purge the gut of toxin; emetics or gastric lavage can also be used if the time since ingestion is brief (only a few hours). Neither the use of antibiotics to eliminate an intestinal source of possible continued toxin production nor the administration of guanidine hydrochloride and other drugs to reverse paralysis is of proven value. Treatment of infant botulism requires supportive care and administration of human botulism immune globulin, which can be obtained by calling the California Department of Health Services at 510-231-7600 or by following the instructions at www.infantbotulism.org. Neither equine antitoxin nor antibiotics have been shown to be beneficial. In wound botulism, equine antitoxin is administered. The wound should be thoroughly explored and debrided, and an antibiotic such as penicillin should be given to eradicate C. botulinum from the site, even though the benefit of this therapy is unproven. Results of wound cultures should guide the use of other antibiotics. Botulinum toxins are being employed for a variety of cosmetic and therapeutic purposes, and new uses are being evaluated. Generalized botulism-like weakness complicating therapy (iatrogenic botulism) has been reported but is rare. Prognosis Type A disease is generally more severe than type B, and mortality rates from botulism are higher among patients above age 60 than among younger
patients. With improved respiratory and intensive care, the case-fatality rate in food-borne illness has been reduced to ~7.5% and is low in infant botulism as well. Artificial respiratory support may be required for months in severe cases. Some patients experience residual weakness and autonomic dysfunction for as long as a year after disease onset. Prevention A pentavalent vaccine (types A through E) is available for use in highly exposed individuals. Spores are highly resistant to heat but can be inactivated by exposure to high temperature (116–121°C) and pressure, as in steam sterilizers or pressure cookers used in accordance with the manufacturer's instructions. Toxin is heat-labile and can be inactivated by exposure to a temperature of 85°C for 5 min. Newly identified cases should be reported immediately to public health authorities. Further Readings Arnon SS et al: Human botulism immune globulin for the treatment of infant botulism. N Engl J Med 354:462, 2006 [PMID: 16452558] ——— et al: Botulinum toxin as a biological weapon, in Bioterrorism: Guidelines for Medical and Public Health Management, DA Henderson et al
(eds). Chicago, AMA Press, 2002, pp 141–165 Cawthorne A et al: Botulism and preserved green olives. Emerg Infect Dis 11:781, 2005 [PMID: 15898180] Caya JG et al: Clostridium botulinum and the clinical laboratorian: A detailed review of botulism, including biological warfare ramifications of botulinum toxin. Arch Pathol Lab Med 128:653, 2004 [PMID: 15163234] Centers for Disease Control and Prevention: Botulism from home-canned bamboo shoots—Nan Province, Thailand. MMWR 55:389, 2006 Chertow DS et al: Botulism in 4 adults following cosmetic injections with an unlicensed highly concentrated botulinum preparation. JAMA 206:2476, 2006 Cooper JG et al: Clostridium botulinum: An increasing complication of heroin misuse. Eur J Emerg Med 12:251, 2005 [PMID: 16175065] Gupta A et al: Adult botulism type F in the United States, 1981-2002. Neurology 65:1694, 2005 [PMID: 16344510]
Lindström M, Korkeala H: Laboratory diagnostics of botulism. Clin Microbiol Rev 19:298, 2006 Montecucco C, Molgo J: Botulinal neurotoxins: Revival of an old killer. Curr Opin Pharmacol 5:274, 2005 [PMID: 15907915] Sobel J: Botulism. Clin Infect Dis 41:1167, 2005 [PMID: 16163636] Bibliography Akbulut D et al: Improvement in laboratory diagnosis of wound botulism and tetanus among injecting illicit-drug users by use of real-time PCR assays for neurotoxin gene fragments. J Clin Microbiol 43:4342, 2005 [PMID: 16145075] Barr JR et al: Botulinum neurotoxin detection and differentiation by mass spectrometry. Emerg Infect Dis 11:157, 2005 Centers for Disease Control and Prevention: Botulism in the United States, 1899-1996: Handbook for epidemiologists, clinicians, and laboratory workers. Atlanta, CDC, 1998 (http://www.bt.cdc.gov/agent/botulism/)
Cherington M: Botulism: Update and review. Semin Neurol 24:155, 2004 [PMID: 15257512] Fox CK et al: Recent advances in infant botulism. Pediatr Neurol 34:149, 2005 Grumelli C et al: Internalization and mechanism of action of clostridial toxins in neurons. Neurotoxicology 26:761, 2005 [PMID: 15925409] Hatheway CL: Botulism: The present status of disease. Curr Top Microbiol Immunol 195:55, 1995 [PMID: 8542759] Horowitz BZ: Botulinum toxin. Crit Care Clin 21:825, 2005 [PMID: 16168317] Pascuzzi RM: Pearls and pitfalls in the diagnosis and management of neuromuscular junction disorders. Semin Neurol 21:425, 2001 [PMID: 11774058] Sandrock CE, Murin S: Clinical predictors of respiratory failure and long term outcome in black tar heroin–associated wound botulism. Chest 120:562,
2002 Shapiro RL et al: Botulism in the United States: A clinical and epidemiologic review. Ann Intern Med 129:221, 1998 [PMID: 9696731] Smith LDS, Sugiyama H: Botulism: The Organism, Its Toxins, the Disease, 2d ed. Springfield, IL, Charles C Thomas, 1988 Sobel J: Foodborne botulism in the United States, 1990-2000. Emerg Infect Dis 10:1606, 2004 [PMID: 15498163] Werner SB et al: Wound botulism in California, 1951–1998: Recent epidemic in heroin injectors. Clin Infect Dis 31:1018, 2000 [PMID: 11049786]