Clostridium botulinum: Difference between revisions

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Clostridium botulinum
(: also added DDx)
(Expanded Differential Diagnosis, added Management and Prognosis)
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*Risk factors are gastrointestinal surgery or illness, such as inflammatory bowel disease
*Risk factors are gastrointestinal surgery or illness, such as inflammatory bowel disease


== Differential Diagnosis ==
==Differential Diagnosis==


* [[Myasthenia gravis]]: lacks autonomic features
*[[Myasthenia gravis]]: lacks autonomic features
* [[Lambert-Eaton myasthenic syndrome]]
*[[Lambert-Eaton myasthenic syndrome]]
*[[Guillain-Barré syndrome]] (acute inflammatory demyelinating polyneuropathy): asymmetric, ascending, and involves sensory nerves; or ataxia, in the Miller-Fisher variant that involves cranial nerves
* [[Guillain-Barré syndrome]]
*[[Tick paralysis]]: [[Dermacentor]] tick still attached
*[[Polio]]: febrile and asymmetric
*Others: [[diphtheria]], [[organophosphate toxicity]], [[brainstem stroke]]

== Diagnosis ==

* Gold standard is the '''mouse bioassay'''
** A mouse is injected with a sample (serum, gastric secretions, stool, or food) and are monitored for paralysis
** Toxin type is determined by administering type-specific antitoxin and monitoring for improvement
* Anaerobic cultures of serum, stool, or food, though low sensitivity
* EMG may show small decrement in motor response or brief small abundant motor unit action potentials (BSAP)

== Management ==

* Call the Botulism Reference Service for Canada (or equivalent): office (613) 957-0902; laboratory (613) 957-0885; after-hours (613) 296-1139
* Supportive care
** Intubation and ventilation if necessary
** Bowel routine including enemas if constipated but without severe ileus
* Antitoxin
** For infants up to 1 year old, BabyBIG (BIG-IV) 50 mg/kg
*** Human-derived
** For children over 1 year and adults, heptavalent botulinum antitoxin (HBAT)
*** Horse-derived
*** Including antitoxins to toxin types A through G
*** Risk of sensitization or anaphylaxis to horse proteins
* Antibiotics
** May cause more toxin to be released from dying bacteria, so generally avoided
** Aminoglycosides and tetracyclines can worsen the paralysis of infant botulism

== Prognosis ==

* Mortality with appropriate treatment is 5 to 8% in adults and 1% in infants
* Takes weeks to months to recover and may have weakness for more than one year
{{DISPLAYTITLE:''Clostridium botulinum''}}
{{DISPLAYTITLE:''Clostridium botulinum''}}
[[Category:Gram-positive bacilli]]
[[Category:Gram-positive bacilli]]

Revision as of 00:27, 14 July 2020

Background

Microbiology

  • Gram-positive anaerobic bacillus with a subterminal spore
  • Diverse species whose defining trait is the production of botulinum toxin
  • Subdivided into four groups based on biochemical tests
  • These strains produce eight toxin types, A through H, that are identified by serology; some strains produce two different toxins

Pathophysiology

  • Botulinum toxins are zinc-dependent metalloproteinases, and inhibit the release of acetylcholine from the presynaptic neuron

Clinical Presentation

  • Typically involves symmetric descending paralysis, starting with cranial nerves and often involving respiratory muscles
  • Afebrile with normal or slow heart rate despite hypotension, and sparing the sensory nerves
  • This presentation contrasts with polio, which can be asymmetric and often has fever

Foodborne botulism

  • Symptoms start 12 to 36 hours after ingestion
  • Nausea, diarrhea, and dry mouth
    • Of note, diarrhea is not caused by the toxin but by other ingested contaminants

Wound botulism

  • Incubation period of t to 14 days
  • May have fever secondary to an infected wound, although the wound can rarely appear to be healing well
  • Can produce abscesses

Infant botulism

  • Classically after ingesting unpasteurized honey
  • Feeding difficulties, hypotonia, drooling, and weak cry
  • Descending paralysis, including upper airway obstruction that may require intubation
  • Distinguishing features are lack of fever, normal CSF
  • Typically worsens over 1 to 2 weeks, then stabilizes for 2 to 3 weeks, then recovers
  • Relapses are possible

Adult intestinal toxemia

  • Rare form of botulism associated with colonisation of the GI tract
  • Onset is more gradual and disease less severe than foodborne botulism
  • Risk factors are gastrointestinal surgery or illness, such as inflammatory bowel disease

Differential Diagnosis

Diagnosis

  • Gold standard is the mouse bioassay
    • A mouse is injected with a sample (serum, gastric secretions, stool, or food) and are monitored for paralysis
    • Toxin type is determined by administering type-specific antitoxin and monitoring for improvement
  • Anaerobic cultures of serum, stool, or food, though low sensitivity
  • EMG may show small decrement in motor response or brief small abundant motor unit action potentials (BSAP)

Management

  • Call the Botulism Reference Service for Canada (or equivalent): office (613) 957-0902; laboratory (613) 957-0885; after-hours (613) 296-1139
  • Supportive care
    • Intubation and ventilation if necessary
    • Bowel routine including enemas if constipated but without severe ileus
  • Antitoxin
    • For infants up to 1 year old, BabyBIG (BIG-IV) 50 mg/kg
      • Human-derived
    • For children over 1 year and adults, heptavalent botulinum antitoxin (HBAT)
      • Horse-derived
      • Including antitoxins to toxin types A through G
      • Risk of sensitization or anaphylaxis to horse proteins
  • Antibiotics
    • May cause more toxin to be released from dying bacteria, so generally avoided
    • Aminoglycosides and tetracyclines can worsen the paralysis of infant botulism

Prognosis

  • Mortality with appropriate treatment is 5 to 8% in adults and 1% in infants
  • Takes weeks to months to recover and may have weakness for more than one year