Wound botulism in drug addicts in the United Kingdom

Clostridium novyi has recently been identified as the causative organism responsible for the deaths of 35 heroin addicts who had injected themselves intramuscularly. We present two heroin addicts who developed C. botulinum infection following intramuscular or subcutaneous injection of heroin. Like C. novyi, this grows under anaerobic conditions and clinical presentation may be similar; however, descending motor or autonomic signs are invariably present in botulism. The prognosis is good if the diagnosis is made early and appropriate treatment commenced.

[Poisoning with botulinum neurotoxin--diagnostic difficulties]

Intoxication with botulinum neurotoxin, which occurs frequently in Poland, may cause serious diagnostic difficulties. As no assays for laboratory detection of botulinum toxin are available and the biological test on mice requires time before results are obtained, diagnosis must be based on clinical findings and patient's epidemiological history. Quick diagnosis and early administration of therapy with equine antitoxin is essential for patient's recovery. The effectiveness of antitoxin therapy is considered to be significantly reduced if the treatment is not started shortly after the onset of the disease. We describe a case of a patient in whom, because of diagnostic difficulties, antitoxin therapy was introduced with much delay. However, it proved highly efficient and lead to gradual recovery.

Clostridium difficile colitis associated with infant botulism: near-fatal case analogous to Hirschsprung's enterocolitis

We present the first five reported cases of Clostridium difficile-associated diarrhea (CDAD) in children with infant botulism caused by Clostridium botulinum. We compare two fulminant cases of colitis in children with colonic stasis, the first caused by infant botulism and the second caused by Hirschsprung's disease. In both children, colitis was accompanied by hypovolemia, hypotension, profuse ascites, pulmonary effusion, restrictive pulmonary disease, and femoral-caval thrombosis. Laboratory findings included pronounced leukocytosis, hypoalbuminemia, hyponatremia, coagulopathy, and, when examined in the child with infant botulism, detection of C. difficile toxin in ascites. CDAD recurred in both children, even though difficile cytotoxin was undetectable in stool after prolonged initial therapy. Four children who had both infant botulism and milder CDAD also are described. Colonic stasis, whether acquired, as in infant botulism, or congenital, as in Hirschsprung's disease, may contribute to the susceptibility to and the severity of CDAD.

Outbreak of type A botulism and development of a botulism surveillance and antitoxin release system in Argentina

CONTEXT

Botulism is an important public health problem in Argentina, but obtaining antitoxin rapidly has been difficult because global supplies are limited. In January 1998, a botulism outbreak occurred in Buenos Aires.

OBJECTIVES

To determine the source of the outbreak, improve botulism surveillance, and establish an antitoxin supply and release system in Argentina.

DESIGN, SETTING, AND PARTICIPANTS

Cohort study in January 1998 of 21 drivers of a specific bus route in urban Buenos Aires.

MAIN OUTCOME MEASURE

Occurrence of botulism and implication of a particular food as the vehicle causing this outbreak.

RESULTS

Nine (43%) of 21 bus drivers developed botulism, presenting with gastroenteritis, symptoms of acute cranial nerve dysfunction including ptosis, dysphagia, blurred vision, and motor weakness. One driver experienced respiratory failure. Type A toxin was detected from 3 of 9 patients' serum samples. All drivers received botulism antitoxin; there were no fatalities. Consumption of matambre (Argentine meat roll) was significantly associated with illness. Among 11 persons who ate matambre, 9 developed illness, compared with none of those who did not eat it (P<.001). The matambre had been cooked in water at 78 degrees C to 80 degrees C for 4 hours, sealed in heat-shrinked plastic wrap, and stored in refrigerators that did not cool adequately. Subsequently, a botulism surveillance and antitoxin release system was established.

CONCLUSIONS

Insufficient cooking time and temperatures, storage in heat-shrinked plastic wrap, and inadequate refrigeration likely contributed to Clostridium botulinum spore survival, germination, and toxin production. A rapid-response botulism surveillance and antitoxin release system in Argentina should provide more timely distribution of antitoxin to patients and may serve as a model for other nations.

Experience with the use of an investigational F(ab')2 heptavalent botulism immune globulin of equine origin during an outbreak of type E botulism in Egypt

During an outbreak of type E foodborne botulism in Cairo in 1991, an investigational equine F(ab')2 "despeciated" heptavalent botulism immune globulin (dBIG) was provided to the Egyptian Ministry of Health by the U.S. Army. Of 54 patients known to have been treated with antitoxins, 4 received commercially available trivalent antitoxins, 45 received dBIG, and 5 received both commercial antitoxin and dBIG. Physicians recorded side effects in 10 (22%) of 45 patients who received dBIG; in nine cases, reactions were considered "mild," and in one case they were believed to be serum sickness. In contrast, possible serum sickness during hospitalization was recorded for two of four patients who were receiving commercial antitoxins. No complications of therapy were noted for any patient who was receiving both antitoxin types. In a separate study, 31 patients were contacted about their reactions to the antitoxin by telephone after discharge from the hospital. Seven (54%) of 13 patients attributed symptoms that they experienced while they were hospitalized to receipt of dBIG, while four (44%) of nine patients who indicated that they had received commercial antitoxins and one (20%) of five who received both commercial antitoxin and dBIG reported side effects before discharge. Data on the efficacy of the antitoxins were not obtained. In our experience, equine dBIG was at least as safe as commercially available antitoxins in treating type E foodborne botulism.

[A new approach to the prevention and treatment of lesions caused by bacterial toxins: prospects for using inhibitors of ADP ribosylation]

The damaging action of a number of bacterial toxins is determined by their capacity for blocking the specific functions of regulatory proteins of eukaryotic cells by ADP-ribosylation. Experiments, made with the use of type B botulinic toxin and 3,N-butyrylaminobenzamide as an example, have demonstrated that specific ADP-ribosylation inhibitors are capable of making up a new group of highly active antagonists of microbial toxins.

Retrospective study of 108 cases of botulism in Poitiers, France

Botulism, a food-borne toxin-mediated disease caused by Clostridium botulinum is still a common disease, which is most frequent in the rural environment; 108 cases, 66 males and 42 females, average age 32 years, were recorded from 1965 to 1990 in the infectious disease department of the University Hospital of Poitiers (France). In 83% of patients, the food responsible was home-cured ham. Mean incubation time was 3.4 days; digestive symptoms were observed in 93% of cases, ocular symptoms in 92% and urinary tract dysfunction in 22%. A scale of severity was used to classify the patients into those suffering from severe (6), intermediate (50) and mild (52) forms of the disease. Botulinum toxin type B was found in 36 (52%) of 69 blood samples and in 41 (51%) of 81 samples of the suspected food. From 1965 to 1976, 44 patients were treated with both toxoid and heterologous equine serotherapy. Since 1976, 29 patients have been treated with guanidine hydrochloride (35 mg/kg daily) and 35 patients with guanidine hydrochloride plus heterologous serotherapy. All 108 patients recovered without any sequelae.

Development of infant botulism in a 3-year-old female with neuroblastoma following autologous bone marrow transplantation: potential use of human botulism immune globulin

Infant botulism is a rare disease caused by the release of toxin produced in the intestinal tract by Clostridium botulinum. The disease primarily affects infants under 1 year of age. We report a 3-year-old child with stage IV neuroblastoma who developed symptoms of progressive motor weakness, bulbar palsy and respiratory failure 42 days after autologous BMT. The diagnosis of infant botulism was established by identifying botulism toxin in the stool. Human botulism immune globulin (HBIG) was administered. Following the diagnosis, the patient made significant recovery over the next 7 weeks and was successfully extubated from mechanical ventilation. However, her neuroblastoma eventually recurred and she subsequently died of progressive disease. Although the etiology of the development of infant botulism in this case following autologous BMT still remains unclear, alteration of the intestinal microbial environment from gut sterilization and laminar airflow room isolation or, alternatively, immune suppression during pre- and post-autologous BMT and activation of endogenous spores may have contributed to the development of this disease. The use of HBIG in children with botulism over 1 year of age may be beneficial.

Human type A botulism and treatment with 3,4-diaminopyridine

3,4-diaminopyridine was evaluated for its ability to improve muscle strength, respiratory function and electromyographic compound muscle action potentials in human botulism. In a double blind, placebo controlled study, 3,4-diaminopyridine failed to improve these parameters in a 31-year old patient with severe food-borne type A botulism. The addition of an anti-cholinesterase medication to the 3,4-diaminopyridine did not add any benefit. Lack of clinical improvement from 3,4-diaminopyridine in this patient differed from some reports of benefit in animals experimentally poisoned with type A botulinum toxin.

Human botulism

The survival of Clostridium botulinum spores in improperly processed foods varies considerably with pH and temperature. The greatest risk arises from commercial or home-prepared condiments, vegetables, non-acid fruits and preserved raw fish. Clinical problems with botulism arise from the rapidity of development, unexpected manifestations involving the autonomic nervous system, including paralytic ileus, gastric dilatation and hypotension, and the need to ensure ventilation.

[Two treated cases of botulism]

Botulism is a severe neuroparalytic disease caused by the neurotoxins of Clostridium botulinum which exert their effects on peripheral nerve junctions. Guillain-Barre syndrome, Myasthenia Gravis, acute Poliomyelitis and diphtheria must be considered in the differential diagnosis. In this study we have discussed two patients who were treated in our clinic, the differential diagnosis and the role of anti-Cholinesterase drugs in the treatment.

[Complex pathogenetic therapy of experimental botulism]

The study of survival and life span of mice and white rats upon the administration of LD50 of the toxin has shown that an antihypoxic agent--gutimine (50-200 mg/kg)--had a protecting effect in type C botulinum intoxication. A combined use of gutimine and 4-aminopyridine (1-5 mg/kg), facilitating a transmitter release in synapses, had a more marked protecting effect in botulinum intoxication. Due to the potentiation of the drugs effect during their combined application, the doses of each drug in the combination could be reduced.

[Botulism: considerations about 8 cases occurred in the Triangulo Mineiro, Minas Gerais, Brazil]

O botulismo constitui uma forma rara de intoxicação alimentar, particularmente em nosso meio. A única epidemia comprovada desta doença no Brasil ocorreu na década de 1950, no Rio Grande do Sul, onde nove pessoas a adquiriram, após a ingestão de conserva caseira de peixe. O presente estudo relata um surto de Botulismo tipo A ocorrido em uma família de 8 membros, dos quais 7 contraíram esta toxinfecção após a ingestão de carne suína conservada sob a forma de enlatado caseiro. Duas pessoas evoluíram para o óbito, e os restantes recuperaram-se após variável tempo de evolução. Onze meses após, diagnosticou-se novo caso desta doença, cuja fonte da intoxicação não pôde ser detectada Os autores pretendem com esta publicação, divulgar a segunda epidemia comprovada de Botulismo no Brasil, e chamar atenção para seu quadro clínico, diagnóstico e tratamento, praticamente desconhecidos em nosso meio.

Ineffectiveness of 3,4-diaminopyridine as a therapy for type C botulism

Clostridium botulinum neurotoxins inhibit acetylcholine release at neuromuscular junctions. Agents stimulating neurotransmitter efflux, such as 3,4-diaminopyridine (3,4-DAP), could be useful for botulism therapy. Treatment with 3,4-DAP (8 mg/kg hourly, beginning 3 hr after toxin injection) failed to increase the survival times of mice receiving 10, 20 or 40 LD50 type C, but did prolong the survival of those receiving 20 LD50 type A. This difference in 3,4-DAP efficacy may reflect variations in the molecular mechanism of action of types A and C botulinum neurotoxins.

Botulism in a patient with jejunoileal bypass

A 45-year-old woman was diagnosed as having the unclassified form of botulism. Her intestines may have been predisposed to colonization with Clostridium botulinum because of a jejunoileal bypass procedure that had been done several years earlier. One other similar case has been reported.

Effect of 3,4-diaminopyridine on the survival of mice injected with botulinum neurotoxin type A, B, E, or F

To determine the efficacy of 3,4-diaminopyridine (3,4-DAP) as a potential treatment for botulism, its effect on the survival times of mice injected with type A, B, E, or F botulinum toxin (Bo Tx) was examined. Mice were injected ip with 10, 20, or 40 LD50 of Bo Tx. Three hours later, when the mice displayed signs of botulism, half of each group of mice was treated with 3,4-DAP, an agent which increases nerve-evoked transmitter release. At each dose of type A Bo Tx tested, 3,4-DAP definitely prolonged survival. In contrast, treatment with the drug did not significantly increase the survival time of mice injected with type B, E, or F Bo Tx. The differences in efficacy of 3,4-DAP against the four serotypes of Bo Tx together with previously reported variations in specific toxicity and duration of paralysis may reflect differences in the pharmacological activity of these neurotoxins.

A preclinical evaluation of aminopyridines as putative therapeutic agents in the treatment of botulism

4-Aminopyridine and 3,4-diaminopyridine were evaluated for their abilities to delay the onset of paralysis due to botulinum neurotoxin types A, B, and E. Experiments were done on phrenic nerve-hemidiaphragm preparations excised from mice. At a concentration that produced an enhancement in muscle twitch amplitude, 4-aminopyridine and 3,4-diaminopyridine delayed the onset of paralysis due to botulinum toxin type A. Under the same conditions, the drugs did little to protect tissues against botulinum toxin types B and E. 3,4-Diaminopyridine was also evaluated for its ability to reverse the paralysis due to botulinum toxin. Experiments were done on rat phrenic nerve-hemidiaphragm preparations that had previously been poisoned in vivo. The drug produced transient increases in neuromuscular transmission, with the effect being greater for botulinum neurotoxin type A than for botulinum neurotoxin types B and E. Equivalent types of experiments were done with tetanus toxin. The results with 3,4-diaminopyridine showed that tetanus toxin resembled botulinum toxin types B and E. The data help to clarify the role of aminopyridines as therapeutic agents in the treatment of botulism. They also provide insights into the mechanism of action of clostridial neurotoxins.

Clostridium botulinum type B toxicosis in a herd of cattle and a group of mules

Clostridium botulinum type B toxicosis was diagnosed as the cause of generalized weakness and death in a group of cows and mules fed from the same batch of rye silage. One severely affected cow was treated and recovered, as did other less severely affected cows. All affected mules died. The remaining cattle in the herd were then vaccinated before continued feeding of the silage.

[Possibilities of pharmacologic correction of Na, K-ATPase activity in the spinal cord in botulism]

The experiments on white rats have shown that gutimin is capable of reactivating Na, K-ATPase of the synaptosomes of the jugular spinal cord in type C botulinic intoxication. Serotonin prevented Na, K-ATPase activity inhibition only in preclinical period of intoxication. Parmidin injection did not prevent suppression of Na, K-ATPase activity either in preclinical period or in skeletal muscle paresis.

Botulism

Clostridium botulinum is ubiquitous in the environment, yet symptoms of botulism occur in humans only if toxin A, B, or E is ingested, absorbed in the intestine, and bound and eventually internalized in the neuronal receptors, producing neuromuscular blockade. Clinically, botulism is divided into four types: food borne, infantile, wound, and unclassified. Systemic neurological symptoms occur within 72 hours of gastrointestinal symptoms and can progress rapidly to respiratory paralysis. Diagnosis depends on a high index of suspicion, but cultures and special tests may be helpful. Treatment remains mostly supportive with good respiratory care emphasized. Use of botulism antitoxin and guanidine may be helpful in some cases.

4-aminopyridine-a review

4-aminopyridine is the first of the aminopyridines to be used in clinical practice. It blocks potassium channels and thereby increases acetylcholine, and possibly noradrenaline, release at nerve terminals. In man the drug has a significant action at the neuromuscular junction, but has little effect on the autonomic nervous system or muscle (smooth, skeletal, or cardiac) although such actions have been demonstrated in animals. It may be clinically useful in the reversal of nondepolariser blockade and a role in antibiotic associated block has been proposed. It may be used effectively as an analeptic agent. It appears to be a useful therapeutic agent in myasthenia gravis and Eaton Lambert syndrome, although of limited use in botulism. It effects on the central nervous system are considerable. These account for the major side effects of the drug which include tremor, excitability and convulsions.

[Diagnostic and therapeutic problems of botulism in infants (author's transl)]

The incidence of botulism remains high. This disease is burdened by a high lethality rate. It is of significant importance for the patient that therapy is instituted sufficiently early. Botulism is an intoxication with the toxin of Clostridium botulinum. In babies, botulism can be caused also by peroral infection with the bacteria or spores. It appears that intestinal germination to toxin-forming bacteria can occur in babies only. Since honey is very frequently contaminated with Clostridium botulinum spores, honey should be eliminated from baby food. The signs manifested in botulism in infants are similar to those in somewhat older children and adults: increasing muscular hypotonia, apathy, pareses of the cranial nerves, and, finally, respiratory insufficiency through paresis of the respiratory musculature. The authors report on their own observations in cases of botulism, and on current possibilities of treatment.

Infant botulism: clinical spectrum and epidemiology

Between 1977 and 1979, 12 cases of infant botulism were diagnosed in Utah, and 87 control patients (normal, nonbotulism neurologic disease, and nonbotulism systemic disease) were evaluated. Observations from these patients suggest an expanded clinical spectrum of infant botulism including asymptomatic carriers of organism; mild hypotonia and failure to thrive; typical cases with constipation, bulbar weakness, and hypotonia; and children with a picture compatible with sudden infant death syndrome. Clostridium botulinum was isolated from the stools of three normal control infants and nine control infants who had neurologic diseases that were clearly not infant botulism. These infants were termed "asymptomatic carriers" of the organism. The occurrence of the asymptomatic carrier state suggests that a diagnosis of infant botulism cannot be made on a basis of culture results alone, but must rest in historical documentation and physical confirmation of progressive bulbar and extremity weakness with ultimate complete resolution of symptoms and findings over a period of several months. A common set of environmental features characterizes the home environment of children with infant botulism and "asymptomatic carriers" and includes: nearby constructional or agricultural soil disruption, dusty and windy conditions, a high water table, and alkaline soil conditions.

Susceptibility of Clostridium botulinum to thirteen antimicrobial agents

A total of 224 strains of Clostridium botulinum (including isolates from 14 patients with infant botulism and 4 with wound botulism) and 15 strains of C. sporogenes were tested by agar dilution for susceptibility to tetracycline, metronidazole, erythromycin, penicillin, rifampin, chloramphenicol, clindamycin, cephalothin, cefoxitin, vancomycin, sulfamethoxazole-trimethoprim, nalidixic acid, and gentamicin. At least 90% of the C. botulinum strains tested (except for nonproteolytic strains of toxin type F with penicillin) were susceptible to all drugs except sulfamethoxazole-trimethoprim, nalidixic acid, and gentamicin. Minimal inhibitory concentrations for strains from patients with infant and wound botulism were similar to those for other C. botulinum strains.

Potentiation of neuromuscular weakness in infant botulism by aminoglycosides

A retrospective study of ten patients with infant botulism who received gentamicin or kanamycin suggests that aminoglycoside antibiotics potentiate muscular weakness and precipitate respiratory failure as late as 27 days after onset of the disease. Although it is difficult to separate progression of the disease from the effects of antibiotics, the rapidity of deterioration following aminoglycoside treatment and the rapidity of recovery following cessation of aminoglycoside therapy is highly suggestive. A review of five patients who received only penicillin or a semisynthetic derivative of penicillin did not reveal any temporal deterioration with onset of penicillin therapy or improvement with cessation of penicillin therapy.

Botulism, type A, and treatment with guanidine

In a double-blind crossover study in which patients received placebo or active drug for varying periods, we evaluated the ability of guanidine hydrochloride (20 to 35 mg/kg per day perorally) to improve the rate of recovery in patients with moderate or severe botulism, type A, intoxication. Among 14 patients who received conventional botulism therapy, there was no improvement in recovery rate in those who received guanidine compared with the nontreated group. Individual patients in the treated group showed neither an acceleration in their rate of improvement when they received guanidine nor a regression in their progress when the drug was stopped. Individual patients, likewise, noted no subjective improvement when they received the drug compared with the placebo. Treatment with guanidine does not enhance recovery from botulism.

The clinical spectrum of infant botulism

Infant botulism is the systemic illness that results when spores of Clostridium botulinum germinate in the infant's intestine and then produce botulinal toxin in vivo. As with other infectious diseases, infant botulism has a spectrum of clinical severity that ranges from a mild, outpatient illness to fulminant, sudden death. Most cases reported to date have been recognized in infants so weak and hypotonic that their need for hospital care was unquestioned; yet even this group of patients displayed a wide range in severity of illness. The outpatients were initially considered to be cases of "failure to thrive," while the fulminant cases were indistinguishable at autopsy from typical instances of the sudden infant death syndrome (SIDS, crib death). This article discusses the observed spectrum of clinical severity, the management of the hospitalized patient, and the manner in which sudden death might result from production of butulinal toxin in the intestine.

Botulism and guanidine. Ten years later

Guanidine hydrochloride was introduced as an adjunct in the treatment of botulism in 1968. It has been reported to be of benefit in 39 cases and of no benefit in 13 cases. No serious side effects have occurred with the short-term therapy required in botulism. Our two cases are similar to earlier cases in that the improvement seen with quanidine therapy is most notable in ocular muscles and least notable in respiratory muscles. Electrophysiological findings again showed an increase in the amplitude of evoked muscle-action potentials after guanidine administration.

Infant botulism: new guise for an old disease

While classic botulism is usually due to preformed toxin in improperly prepared food, the newly recognized infant syndrome occurs when spores or vegetative cells germinate in the gut of the very young and elaborate toxin there. The resulting illness may range from inapparent to fulminant, sometimes causing respiratory arrest and death. Infant botulism may also account for at least some cases of sudden infant death syndrome.