Botulism
Cluster of wound botulism in injecting drug users
Information from National Disease Surveillance Centre.
Four cases of botulism have been reported in injecting drug
users (IDU's) Dublin in 2008.
- All cases had a flaccid paralysis.
- These cases may be caused by a batch of drugs contaminated with the anaerobic bacterium Clostridium botulinum.
In the USA, botulism is particularly associated with skin popping "black tar" heroin (oily paste is a good vehicle to carry the organism).
A single (2008) case in CUH was diagnosed following ingestion of contaminated food.
Causative organism
The symptoms of botulism are caused by a toxin produced by the gram positive, anaerobic,
spore forming bacterium Clostridium botulinum. The toxin blocks
the release of acetycholine at the neuromuscular junction resulting
in a descending flaccid paralysis. Botulism is not spread from
one person to another.
There are three naturally occurring forms of botulism:
- Food-borne botulism, caused by ingestion of pre-formed toxin
- Wound botulism, which occurs when C. botulinium spores contaminate a wound, germinate and produce toxin in vivo
- Intestinal colonisation botulism, usually seen in infants
Clinical features
Afebrile
Descending
Flaccid Paralysis
Patients with botulism typically present with
- difficulty speaking, seeing and/or swallowing
- may have double vision, blurred vision, drooping eyelids,
- slurred speech, difficulty swallowing, and muscle weakness (later, loss of tendon reflexes)
- paralysis may progress to the arms, legs, trunk and respiratory muscles
- usually no fever
- no loss of sensation
- no loss of awareness
There may also be autonomic signs with
- dry mouth, fixed or dilated pupils
- cardiovascular, gastrointestinal and urinary dysfunction
If onset is very rapid, there may be no symptoms before sudden respiratory paralysis occurs, which may be fatal. Recovery can take months.
Differential dx of BOTULISM
- Guillian Barré(Miller Fisher)
- Paralytic shellfish poisoning
- Organophosphate poisoning
- Myaesthenia gravis
- Tick paralysis
- Encephalitides
Laboratory
Confirmation of the clinical diagnosis is by the demonstration of botulinum
toxin in blood samples or, in the case of wound botulism, by the identification
of C. botulinum in wound specimens. Specimens should be sent immediately
to the reference laboratory.
Samples to be taken from acutely ill patients include:
- Serum. At least 10ml. Serum samples must be collected before antitoxin is administered
- Wound. Pus. As much as possible in a sterile container. (If no pus - swab in anaerobic culture medium)
- Biopsy tissues. If surgical debridement is performed, biopsy tissues should be placed immediately into a sterile container.
- Post mortem specimens. Heart blood (10ml), if not haemolysed, should be sent for serum for serum collection. Specimens from infected wounds may also be useful.
- All samples must be kept refrigerated after collection
All specimens should be sent directly to the reference laboratory with the sender's name and address clearly marked. Call the reference laboratory prior to sending the sample.
Out of office hours, contact
Clinical management
Botulism Antitoxin
Botulism anti-toxin (if required) can be procured by contacting: Dr. Seamus O’Dea, Cherry Orchard
Tel 01 620 6000 (or medical officer on call)
- Specialist advice should be urgently sought from an Infectious
Diseases Physician or Microbiologist
- Botulinum antitoxin is effective in reducing the severity
of symptoms if administered early in the course of the disease
- C. botulinum is sensitive to benzyl penicillin and metronidazole.
- In cases of wound infection, antimicrobial therapy and surgical debridement should reduce the organism load and
therefore toxin production, but circulating toxin can only be
neutralised by the early administration of antitoxin.
- Where there is definite clinical suspicion of botulism, treatment with antitoxin should not be delayed for microbiological testing.
Reporting & public health investigation
- Food samples associated with suspected cases of food borne botulism must be obtained as a matter of extreme urgency in order to prevent further cases.
- Reference for this page is : CEM/CMO/2002/14 Full document.
Links
- National Disease Surveillance Centre Virus Reference Laboratory Belfield
- Food Safety Authority Ireland alert November 2011
- Please inform pharmacy that you are requesting the anti-toxin - it is an unlicensed product details at NIO site
- Botulism Antitoxin SPC
- Botulism Antitoxin product
- Botulism Antitoxin Local (HSE) version
