Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 33-05: Clostridial Diseases + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ Recent ingestion of home-canned or smoked foods Recent injection drug use Recovery of toxin in serum or food Diplopia, dry mouth, dysphagia, dysphonia Muscle weakness leading to respiratory paralysis; normal sensory examination Pupils are usually fixed and dilated +++ General Considerations ++ A paralytic disease caused by botulinum neurotoxin, which is produced by Clostridium botulinum, a ubiquitous, strictly anaerobic, spore-forming bacillus found in soil Four toxin types—A, B, E, and F—cause human disease Botulinum toxin inhibits release of acetylcholine at the neuromuscular junction Naturally occurring botulism exists in three forms Food-borne botulism Infant botulism Wound botulism Food-borne botulism is caused by ingestion of preformed toxin present in canned, smoked, or vacuum-packed foods such as home-canned vegetables, smoked meats, and vacuum-packed fish Infant botulism Associated with ingestion of honey Honey consumption is safe for children 1 year of age or older Wound botulism Often occurs in association with injection drug use Results from organisms present in the gut or wound that secrete toxin Botulinum toxin Extremely potent Classified by the Centers for Disease Control and Prevention (CDC) as a high-priority agent because of its potential to be used a bioterrorism agent +++ Demographics ++ Approximately 170 cases of botulism have been reported to the CDC over a year. Of these, 20% were food-borne and wound botulism and the remainder were infant botulism + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs ++ Visual disturbances, particularly diplopia and loss of accommodation, appear 12–36 h after ingestion of the toxin Characteristic signs Ptosis Cranial nerve palsies with impairment of extraocular muscles Fixed dilated pupils Other symptoms Dry mouth Dysphagia Dysphonia The sensory examination is normal The sensorium remains clear and the temperature normal Respiratory paralysis may lead to death unless mechanical assistance is provided +++ Differential Diagnosis ++ Because the clinical presentation of botulism is so distinctive and the differential diagnosis limited, botulism once considered is not easily confused with the other diseases listed below Poliomyelitis Guillain-Barré syndrome Myasthenia gravis Brainstem infarct or vertebrobasilar insufficiency Tick paralysis Organophosphate poisoning + Diagnosis Download Section PDF Listen +++ ++ Toxin in food and patients' serum may be shown by mouse inoculation and identified with specific antiserum + Treatment Download Section PDF Listen +++ +++ Medications ++ If botulism is suspected Contact the CDC for advice and help with procurement of equine serum heptavalent botulism antitoxin and for assistance in obtaining assays for toxin Skin testing is recommended to exclude hypersensitivity to antitoxin preparation Antitoxin should be given as early as possible, ideally within 24 h of onset of symptoms or signs, to arrest progression of disease Do not delay administration of antitoxin to await laboratory confirmation of diagnosis During off hours, the CDC provides assistance via a recorded message at 404-639-2206 +++ Therapeutic Procedures ++ Respiratory failure is managed with intubation and mechanical ventilation + Outcome Download Section PDF Listen +++ +++ Prevention ++ Botulism toxin is destroyed by high temperatures; persons who eat home-canned foods should consider boiling the food for 10 min before eating it +++ Prognosis ++ Early nervous system involvement leads to respiratory paralysis and death in untreated cases +++ When to Refer ++ All cases should be reported to the public health authorities Obtain immediate consultation with infectious disease and neurology experts +++ When to Admit ++ All suspected and proven cases because of the high fatality rate + References Download Section PDF Listen +++ + +Adalja AA et al. Clinical management of potential bioterrorism-related conditions. N Engl J Med. 2015 Mar 5;372(10):954–62. [PubMed: 25738671] + +Schulte M et al. Effective and rapid treatment of wound botulism, a case report. BMC Surg. 2017 Oct 26;17(1):103. [PubMed: 29073888]