Signs and symptoms predictive of death in patients with foodborne botulism--Republic of Georgia, 1980-2002

The First Reported Foodborne Botulism Outbreak in Riyadh, Saudi Arabia: Lessons Learned

BACKGROUND

Botulism has not been previously reported in the Kingdom of Saudi Arabia. This rare and sometimes fatal foodborne illness is caused by neurotoxins and primarily results from consuming home-canned fruits, vegetables, dairy, and seafood products & it can lead to paralysis.

OBJECTIVE

The purpose of this study was to evaluate the clinical features of patients who developed botulism in Riyadh in 2024 after consuming mayonnaise from a well-known local chain of restaurants in Riyadh, Saudi Arabia.

METHODS

We conducted a retrospective analysis of medical records and interviewed patients or their attendants for all hospitalized cases of foodborne botulism at Riyadh First Health Cluster. For each patient, a standard case report form was completed, containing information on demographics, clinical aspects, botulinum test results, and type of exposure. Descriptive statistics were applied to assess the data. During the outbreak, nineteen patients with foodborne diseases were admitted to Riyadh First Health Cluster Hospitals. Following thorough physical examinations, botulism was suspected in each case.

RESULTS

Eight of the 19 suspected foodborne illness patients fully satisfied the botulism case definition requirements set forth by the Saudi Arabian Public Health Authority (Weqaya). Among these eight patients, 2 (25%) were male and 6 (75%) were female, with a mean age of 23.25 ± 9.29 years (range: 12-38 years). The incubation period for our patients was 36.25 ± 26.26 h. Notable symptoms included dysphagia in all eight patients (100%), dysarthria, generalized weakness, nausea and vomiting in seven patients (88%), diplopia in four patients (50%), and stomach discomfort in three patients (38%). Of the eight cases, six required intubation, one mimicked brain death, and two were stable. The presence of Clostridium botulinum spores as the cause of the outbreak was confirmed by detecting botulinum spores in contaminated food.

CONCLUSION

Diplopia and dysarthria were the most common early sign of botulism. Early manifestations may include respiratory symptoms without any musculoskeletal symptoms. or nausea, vomiting and disorientation.

Clinicopathological insights into an outbreak of foodborne botulism in Hamadan, Iran, in 2023: A microbiological and laboratory findings

Background and Objective

Foodborne botulism is one of the potentially fatal forms of food poisoning, usually caused by ingestion of home-canned vegetables, fruits, and dairy and fish products. This study aimed to assess the frequency of signs and symptoms in patients with botulism following the ingestion of homemade Doogh, a traditional milk-based beverage, in Hamadan, Iran in 2023. We also examined the general characteristics of the recruited patients.

Methods

During an outbreak, 21 patients were referred to the hospital because of food poisoning. All patients had a history of consumption of Doogh. After careful physical examination, all of them were hospitalized. Botulism was suspected in all patients except for the first patient.

Results

The mean age of admitted patients was 33.09 ± 18.44 years, with 23.80% being males and 76.20% females. Incubation period in our patients was 68 ± 28.48 h. Notable symptoms included diplopia (95.23%), nausea and vomiting (85.71%), blurred vision (80.95%), and dizziness (61.90%). The laboratory results were within the normal range. No deaths occurred in this patient cohort. Furthermore, botulinum spores were detected in Doogh samples collected from the outbreak, confirming the presence of Clostridium botulinum spores as a source of the outbreak.

Conclusions

This study highlights that the initial manifestations of botulism predominantly involved ophthalmologic abnormalities in most patients. Additionally, symptoms such as nausea, vomiting, and dizziness may manifest in cases of foodborne botulism. Timely diagnosis and treatment of botulism following the consumption of homemade Doogh played a crucial role in achieving positive outcomes, with no fatalities recorded in this patient cohort.

Food-borne botulism from homemade sauce leading to cardiac arrest: A family case series with literature review

Food-borne botulism is a rare but potentially fatal illness. Its management depends on rapid diagnosis and prompt antitoxin administration. However, diagnosing food-borne botulism can be challenging at an early stage. Here, we report a 62-year-old male with food-borne botulism. The patient presented with extremity muscle weakness, dyspnea, bilateral droopy eyelids (more significant on the right side), dysarthria, and progressive dysphagia. The electromyography indicated presynaptic membrane abnormalities. The toxicology screen reported a positive result for botulinum toxin type A. He received plasma exchange, botulism antitoxin, and supportive care. However, he had a cardiac arrest six days later. Spontaneous circulation was restored after immediate cardiopulmonary resuscitation. The patient gradually recovered his muscle strength and could have complete eyelid elevation. A detailed interview revealed that six family members developed similar symptoms. All of them consumed a homemade sauce prepared three years ago. They all tested positive for botulinum toxin type A. Two of them had cardiac arrests. Therefore, family aggregation could happen to botulism. Careful interviews, early diagnosis, and timely administration of botulism antitoxin are the keys to saving lives. Special attentions should be given to the cardiac evaluations since botulism can cause cardiac arrest and death.

Foodborne botulism and the importance of recognizing the disease in the emergency department: a case report

BACKGROUND

Botulism is a rare neuroparalytic disease that has only presented itself 19 times in the last 30 years in Belgium. Patients present to emergency services with a wide range of complaints. Foodborne botulism is a forgotten yet life-threatening disease.

CASE PRESENTATION

We describe a case of a Caucasian female in her 60s that presented to the emergency with reflux with nausea and spasmodic epigastric pain, no vomiting, dry mouth, and weakness in both legs. The symptoms started after ingestion of Atlantic wolffish. After exclusion of other more common causes, foodborne botulism was suspected. The patient was admitted to the intensive care unit for mechanical ventilation. Following treatment with trivalent botulinum antitoxin, she made a full neurologic recovery.

CONCLUSION

It is important to rapidly recognize the possible diagnosis of botulism even if the neurological symptoms are not dominant. Rapid neurologic dysfunction and respiratory difficulties starts between 6 and 72 hours after ingestion. The decision to administer antitoxins should, however, be based on the presumptive clinical diagnosis and diagnosis should not delay therapy.

Botulism outbreak in a rural Ethiopia: a case series

BACKGROUND

Foodborne botulism, a toxin-mediated illness caused by Clostridium botulinum, is a public health emergency. Types A, B, and E C. botulinum toxins commonly cause human disease. Outbreaks are often associated with homemade and fermented foods. Botulism is rarely reported in Africa and has never been reported in Ethiopia.

CASE PRESENTATION

In March 2015, a cluster of family members from the Wollega, Oromia region, western Ethiopia presented with a symptom constellation suggestive of probable botulism. Clinical examination, epidemiologic investigation, and subsequent laboratory work identified the cause of the outbreak to be accidental ingestion of botulinum toxin in a traditional chili condiment called "Kochi-kocha," cheese, and clarified butter. Ten out of the fourteen family members who consumed the contaminated products had botulism (attack rate 71.4%) and five died (case fatality rate of 50%). Three of the patients were hospitalized, they presented with altered mental status (n = 2), profound neck and truncal weakness (n = 3), and intact extremity strength despite hyporeflexia (n = 3). The remnant food sample showed botulinum toxin type A with mouse bioassay and C. botulinum type A with culture. Blood drawn on day three of illness from 2/3 (66%) cases was positive for botulinum toxin type-A. Additionally, one of these two cases also had C. botulinum type A cultured from a stool specimen. Two of the cases received Botulism antitoxin (BAT).

CONCLUSION

These are the first confirmed cases of botulism in Ethiopia. The disease occurred due to the consumption of commonly consumed homemade foods. Definite diagnoses of botulism cases are challenging, and detailed epidemiologic and laboratory investigations were critical to the identification of this case series. Improved awareness of botulism risk and improved food preparation and storage may prevent future illnesses. The mortality rate of botulism in resource-limited settings remains high. Countries should make a concerted effort to stockpile antitoxin as that is the easiest and quickest intervention after outbreak detection.

Suspected botulism outbreak after the consumption of vegetarian pâté in the south of Viet Nam

Botulism and other botulinum neurotoxins-producing clostridia  are potentially life-threatening diseases caused by toxins produced by Clostridium botulinum. Here we reported a case series of six patients who presented with botulism following ingestion of commercially made pâté. The key features of presentation were acute onset of bilateral cranial nerve palsies and symmetrical descending weakness in the absence of fever resulting in the need for mechanical ventilation in all six patients. The clinical diagnosis of botulism was confirmed through the identification of C. botulinum from the suspected food source.  Given that botulinum antitoxin was not available in Vietnam at the time, and their severe status, all patients received a trial of plasma exchange therapy, but no clear benefit was seen. Due to its rarity, diagnosing botulism is a challenge, demanding high clinical suspicion. Successful outcomes depend upon early recognition and rapid initiation of specific treatment with botulinum antitoxin. There is a need to improve global access to antitoxin.  These cases, the first in Viet Nam, serve as a reminder of the need to maintain the highest possible food hygiene and preservation practices.

Botulism outbreak after the consumption of vegetarian pâté in the south of Viet Nam

Botulism is a potentially life-threatening disease caused by toxins produced by Clostridium botulinum. Here we reported a case series of six patients who presented with botulism following ingestion of commercially made pâté. The key features of presentation were acute onset of bilateral cranial nerve palsies and symmetrical descending weakness in the absence of fever resulting in the need for mechanical ventilation in all six patients. The clinical diagnosis of botulism was confirmed through the identification of C. botulinum from the suspected food source.  Given that botulinum antitoxin was not available in Vietnam at the time, and their severe status, all patients received a trial of plasma exchange therapy, but no clear benefit was seen. Due to its rarity, diagnosing botulism is a challenge, demanding high clinical suspicion. Successful outcomes depend upon early recognition and rapid initiation of specific treatment with botulinum antitoxin. There is a need to improve global access to antitoxin.  These cases, the first in Viet Nam, serve as a reminder of the need to maintain the highest possible food hygiene and preservation practices.

Emergency response to a cluster of suspected food-borne botulism in Abuja, Nigeria: challenges with diagnosis and treatment in a resource-poor setting

Food-borne botulism is a rare, acute and potentially fatal neurologic disorder that results from ingestion of food contaminated by botulinum toxin released from the anaerobic, spore-forming, gram-positive bacterium Clostridium botulinum. We reported an unusual cluster of botulism outbreak with high case fatality affecting a family following ingestion of home-made fish. A suspected outbreak of botulism affecting three patients in a family of six was reported to the Nigeria Centre for Disease Control. A rapid response team investigated by line-listing all the family members, interviewed extended family members, caregivers, clinicians, and nurses to collect socio-demographic and clinico epidemiological information using a semi-structured questionnaires. We collected blood from patients and food samples and locally made drink from the family home for laboratory testing. All family members ingested the same home-made food within the 48hrs before onset of symptoms in the index case. The clinical presentation of the three affected cases (AR=50.0%) was consistent with botulinum poisoning. Two of the affected cases died (CFR=66.7%) within 48hrs of admission, before antitoxin was made available. The third case had a milder presentation and survived, after administration of appropriate antitoxin. The remaining three children developed no symptoms. None of the samples cultured Clostridium botulinum. The blood samples were negative for mouse lethality test. Our report describes the challenges of diagnosis and management of rare emerging infectious disease outbreaks in resource-constrained settings.

Clinical Predictive Values in Botulism: A 10-year Survey

Background

Botulism occurs periodically or in outbreaks in Iran. Botulism is lethal and accordingly a considerable issue in environmental health, although it is uncommon. This study was performed to evaluate the potential predictive factors in foodborne botulism in a 10-year span.

Materials and methods

All medical records from patients with foodborne botulism admitted to Imam Reza Hospital in 10 years (2005-2015) were analyzed retrospectively.

Results

61 cases were included (38 men, mean age ± SD 28.93 ± 19.14 years). All cases were treated with antitoxin. 6.6% of cases died. Canned beans were correlated with the admission to intensive care unit (ICU), and also, it increased the length of ICU stay significantly (P = 0.007 and 0.023, respectively). The incidence of dizziness and diplopia significantly induced excess demands for higher doses of antitoxin (P = 0.038 and 0.023, respectively). Risk of dysphagia was remarkably higher in cases with ptosis (P = 0.039, odds ratio: 3). While in this study, time elapsed between the onset of clinical manifestations and antitoxin administration was correlated with the occurrence of dysphagia, constipation, and blurred vision, and early treatment did not improve the outcomes. Multiple analysis of potential variables by a logistic regression model disclosed that the independent significant factors affecting mortality were the need for mechanical ventilation (P = 0.000), dyspnea (P = 0.044), general weakness (P = 0.044), and lack of consciousness (P = 0.008) at the time of admission.

Conclusions

Taking clinical signs and symptoms into account upon patient arrival is important and, of course, is a key to further management in the emergency setting.

How to cite this article

Saeidi S, Dadpour B, Jarahi L, Ghamsari AA, Nooghabi MN. Clinical Predictive Values in Botulism: A 10-year Survey. Indian J Crit Care Med 2021;25(4):411-415.

Botulism outbreak after the consumption of vegetarian pâté in the south of Viet Nam

Botulism is a potentially life-threatening disease caused by toxins produced by Clostridium botulinum. Here we reported a case series of six patients who presented with botulism following ingestion of commercially made pâté. The key features of presentation were acute onset of bilateral cranial nerve palsies and symmetrical descending weakness in the absence of fever resulting in the need for mechanical ventilation in all six patients. The clinical diagnosis of botulism was confirmed through the identification of C. botulinum from the suspected food source.  Given that botulinum antitoxin was not available in Vietnam at the time, and their severe status, all patients received a trial of plasma exchange therapy, but no clear benefit was seen. Due to its rarity, diagnosing botulism is a challenge, demanding high clinical suspicion. Successful outcomes depend upon early recognition and rapid initiation of specific treatment with botulinum antitoxin. There is a need to improve global access to antitoxin.  These cases, the first in Viet Nam, serve as a reminder of the need to maintain the highest possible food hygiene and preservation practices.

Botulism outbreak after the consumption of vegetarian pâté in the south of Viet Nam

Botulism is a potentially life-threatening disease caused by toxins produced by Clostridium botulinum. Here we reported a case series of six patients who presented with botulism following ingestion of commercially made pâté. The key features of presentation were acute onset of bilateral cranial nerve palsies and symmetrical descending weakness in the absence of fever resulting in the need for mechanical ventilation in all six patients. The clinical diagnosis of botulism was confirmed through the identification of C. botulinum from the suspected food source.  Given that botulinum antitoxin was not available in Vietnam at the time, and their severe status, all patients received a trial of plasma exchange therapy, but no clear benefit was seen. Due to its rarity, diagnosing botulism is a challenge, demanding high clinical suspicion. Successful outcomes depend upon early recognition and rapid initiation of specific treatment with botulinum antitoxin. There is a need to improve global access to antitoxin.  These cases, the first in Viet Nam, serve as a reminder of the need to maintain the highest possible food hygiene and preservation practices.

Clinical Characteristics and Ancillary Test Results Among Patients With Botulism-United States, 2002-2015

Background

Botulism is classically described as a bilateral, symmetric, descending flaccid paralysis in an afebrile and alert patient without sensory findings. We describe the reported spectrum of clinical findings among persons >12 months of age in the United States during 2002-2015.

Methods

The Centers for Disease Control and Prevention collects clinical findings reported by physicians treating suspected cases of botulism nationwide. We analyzed symptoms and signs, and neuroimaging and cerebrospinal fluid (CSF) results. A case was defined as illness compatible with botulism with laboratory confirmation or epidemiologic link to a confirmed case, and presence or absence of at least 1 sign or symptom recorded. Physicians' differential diagnoses were evaluated.

Results

Clinical information was evaluated for 332 botulism cases; data quality and completeness were variable. Most had no fever (99%), descending paralysis (93%), no mental status change (91%), at least 1 ocular weakness finding (84%), and neuroimaging without acute changes (82%). Some had paresthesias (17%), elevated CSF protein level (13%), and other features sometimes considered indicative of alternative diagnoses. Five of 71 (7%) cases with sufficient information were reported to have atypical findings (eg, at least 1 cranial nerve finding that was unilateral or ascending paralysis). Illnesses on the physician differential included Guillain-Barré syndrome (99 cases) and myasthenia gravis (76 cases) and, rarely, gastrointestinal-related illness (5 cases), multiple sclerosis (3 cases), sepsis (3 cases), and Lyme disease (2 cases).

Conclusions

Our analysis illustrates that classic symptoms and signs were common among patients with botulism but that features considered atypical were reported by some physicians. Diagnosis can be challenging, as illustrated by the broad range of illnesses on physician differentials.

Foodborne Botulism: Neglected Diagnosis

Botulism is rare neuroparalytic disease caused by botulinum toxin, one of the most toxic substances known. Foodborne botulism is caused by consumption of foods contaminated with botulinum toxin. The clinical manifestations are flaccid, symmetrical, descending paralysis affecting cranial and peripheral nerves. The only specific treatment is botulinum antitoxin. We report the case of a 37-year-old man with gastrointestinal manifestations and posterior cranial nerve palsy who was diagnosed with botulism infection. Clinicians should be aware of rare causes of infection and determine the aetiology of symptoms.

LEARNING POINTS

Botulism remains a diagnostic challenge.Misdiagnosis of early cases suggests sporadic cases are overlooked.Timely clinical diagnosis is critical for treatment decisions as botulinum antitoxin cannot reverse existing paralysis.

Botulism and Bioterrorism: How Serious is This Problem?

Botulism is a potentially lethal disease caused by one of seven homologous neurotoxic proteins usually produced by the bacterium,Clostridium botulinum. This neuromuscular disorder occurs through an exquisite series of molecular events, ultimately ending with the arrest of acetylcholine release and hence, flaccid paralysis. There are three types of botulism: food, wound, and infant botulism. Most strains of the bacterium produce a potent, respiratory muscle-paralyzing neurotoxin, botulinum toxin (BTX). It can lead to death unless appropriate therapy is promptly initiated. Due to the severity and potency of BTX, its importance as a biological weapon is of major concern to public health officials. Nevertheless, BTX is also medicament.

Botulism Outbreak in a Regional Community Hospital: Lessons Learned in Transfer and Transport Considerations

Botulism is a potentially lethal disease caused by a toxin released by Clostridium botulinum. Outbreaks of botulism from food sources can lead to a Mass Casualty Incident (MCI) involving sometimes hundreds of individuals. We report on a recent outbreak of botulism treated at a regional community hospital with a focus on emergency medical services (EMS) response and transport considerations. Case Presentation: There were 53 patient evaluated for botulism at the sending facility. In total, 11 botulism exposures required intubation at the sending facility. Twenty-four patients were ultimately transported by critical care capable ALS crews with the majority (16) of these transports occurred in the first 24 hours. There was one fatality in the first days of the outbreak and a second death that occurred in a patient who died after long-term acute care (LTAC) placement several months after hospital discharge. Conclusion: Local EMS providers and public safety officers have a critical role in identifying and following up on potentially exposed botulism cases. The organization of transporting agencies and the logistics of transfer turned out to be 2 opportunities for improvement in response to this mass casualty incident.

Emergency Neurological Life Support: Acute Non-traumatic Weakness

Acute non-traumatic weakness may be life-threatening if it involves the respiratory muscles and/or is associated with autonomic dysfunction. Most patients presenting with acute muscle weakness have a worsening neurological disorder that requires a rapid, systematic evaluation and detailed neurological exam to localize the disorder. Urgent laboratory tests and neuroimaging are needed to confirm the diagnosis. Because acute weakness is a common presenting sign of neurological emergencies, it was chosen as an Emergency Neurological Life Support protocol. Causes of acute non-traumatic weakness are discussed here by both presenting clinical signs and anatomical location. For each diagnosis, key features of the history, examination, investigations, and treatment are outlined in the included tables or in the "Appendix".

Therapeutic efficacy of equine botulism antitoxin in Rhesus macaques

Background

There are currently no licensed vaccines available for prevention of botulism in humans. The vaccination is not desirable due to expanding therapeutic indications of botulinum toxins. The only available specific treatment for botulism is antitoxin to remove circulating toxin, thus, preventing further neuronal damage. BAT^® (Botulism Antitoxin Heptavalent (A, B, C, D, E, F, G)—(Equine)) has been developed and its therapeutic efficacy evaluated against botulinum neurotoxin serotype A (BoNT/A) in Rhesus macaques.

Methods and findings

In a post-exposure prophylaxis (PEP) study, animals were exposed to 4x LD₅₀/kg of BoNT/A and administered intravenously with either BAT (1x or 0.1x scaled human dose), or placebo at 4 hours post-exposure. The animals were monitored for 14 days. For the therapeutic intervention studies, animals were exposed to a 1.7x LD₅₀/kg of BoNT/A and treated intravenously with either placebo or BAT at a 1x scaled human dose at the onset of clinical signs. Animals were monitored on an hourly basis for 14 or 21 days. In the PEP study, all animals tolerated equine based antitoxin without any adverse clinical signs. A 100% survival was observed in groups treated with the BAT compared to 0% survival in those treated with the placebo (p<0.001, Fisher’s exact test). BAT antitoxin prevented the development of signs of neurotoxicity of botulinum toxin. In a therapeutic study, treatment with the BAT at scaled 1x human dose after the onset of clinical signs significantly enhanced survival compared to the placebo (46.6% vs. 0%, p<0.0001, Fisher’s exact test). Additionally, treatment with the BAT delayed the progression of signs (muscular weakness, respiratory distress, oral/nasal discharge) of toxin intoxication and reduced the severity of the disease.

Conclusions

A single dose of BAT, when administered to symptomatic monkeys, resulted in a statistically significant survival benefit compared to the placebo. Additionally, BAT completely protected monkeys from the clinical signs of intoxication and subsequent death when administered as PEP treatment. These data in part supported the licensure of BAT under the Animal Rule in the United States by the Food and Drug Administration.

Botulism Outbreak in a Family after Ingestion of Locally Produced Cheese

Botulism is one of the most important foodborne diseases and is caused by Clostridium botulinum toxin. The main manifestations are flaccid muscle paralysis and cranial nerve palsies. Botulism is an essential health problem because of its high mortality. The diagnosis of botulism, especially in sporadic cases, is a medical challenge and a high clinical suspicion is necessary for early recognition. So, every physician should be familiar with its signs and symptoms for early detection and treatment. We describe a family with dysphasia and acute paralysis after the ingestion of locally made cheese. The clinical presentations of the 1st patient were similar to myasthenic crisis and she, therefore, received plasma exchange. After the appearance of similar symptoms in the other family members, they were treated with polyvalent botulinum antitoxin and diagnosis was confirmed by toxicology and detection of serotype A botulinum toxin in cheese and stool samples. Uncommon clinical presentations and unusual sources of botulinum toxin should be kept in mind because of the importance of early diagnosis and treatment.

A botulism outbreak from roasted canned mushrooms

Food-borne botulism is a rare disease that results from ingestion of the toxins produced by Clostridium botulinum. The most common cause of the disease is the consumption of home-canned foods prepared under inappropriate conditions, especially in rural environments. In this report, a food-borne botulism outbreak potentially caused by roasted home-canned mushrooms is evaluated and the major reasons for delayed diagnosis are emphasized. The clinical features, symptoms and prognosis of the five botulism patients involved in this outbreak are presented. The clinical progressions, treatments, durations of mechanical ventilation, intensive care unit stays and hospital stays of the three patients admitted to Akdeniz University Hospital are reported.

Buckwheat phenolic metabolites in health and disease

Buckwheat (Fagopyrum esculentum Moench, F. tataricum Gaertner) groats and flour have been established globally as nutritional foods because of their high levels of proteins, polyphenols and minerals. In some regions, buckwheat herb is used as a functional food. In the present study, reports of in vitro studies, preclinical and clinical trials dealing with the effect of buckwheat and its metabolites were reviewed. There are numerous reports of potential health benefits of consuming buckwheat, which may be in the form of food, dietary supplements, home remedies or possibly pharmaceutical drugs; however, adverse effects, including those resulting from contamination, must be considered. There are reports of antioxidative activity of buckwheat, which contains high levels of rutin and quercetin. On the other hand, both cytotoxic and antigenotoxic effects have been shown. Reduction of hyperlipidaemia, reduction of blood pressure and improved weight regulation have been suggested. Consuming buckwheat may have a beneficial effect on diabetes, since lower postprandial blood glucose and insulin response have been reported. In addition, buckwheat metabolites, such as rutin, may have intrinsic protective effects in preserving insulin signalling. Rutin has also been suggested to have potential therapeutic applications for the treatment of Alzheimer’s disease. The literature indicates that buckwheat is safe to consume and may have various beneficial effects on human health.

Botulism with Unusual Rapid Progression to Complete Paralysis in a Child

Botulism is a severe neuroparalytic illness which is difficult to diagnose accurately, especially in children. We report a child with type A botulism intoxication, with very rapid progression to coma-like consciousness and respiratory failure. Careful physical examinations led to the suspicion of botulism, and electrophysiologic examinations, including electroencephalogram and repetitive nerve stimulation tests, further supported the diagnosis. Hospitalization due to botulism had a great emotional impact on the patient and psychological support was crucial.

Two-family outbreak of botulism associated with the consumption of smoked ribs in Sichuan Province, China

BACKGROUND

On September 22, 2013, two patients from Sichuan Province, China presented with symptoms of food-borne botulism, a rare but fatal illness caused by the consumption of foods containing Clostridium botulinum neurotoxins.

METHODS

Investigators reviewed the medical charts and food consumption histories, and interviewed patients and family members. Food samples and clinical specimens were tested for botulinum toxin and neurotoxin-producing Clostridium species by standard methods.

RESULTS

The first two index cases presented with cranial neuropathies and flaccid paralysis, and required mechanical ventilation. There were 12 confirmed outbreak-associated cases. Botulinum toxin type A was identified in the smoked ribs, and all of the patients had consumed the smoked ribs from the same local restaurant. The smoked ribs contained no added salt, sugar, or preservative. Botulinum toxin production likely resulted from the cold-smoking preparation method and inappropriate refrigeration.

CONCLUSIONS

Smoked ribs produced by a local restaurant, contaminated with type A botulism, was the contributor to this outbreak. The supervision of food safety should be strengthened to prevent future outbreaks in China.

Foodborne illness

While few patients with foodborne illness present with life-threatening symptoms, there are a number of foodborne infectious diseases and toxins that the emergency physician or other health care provider must consider in the evaluation of these patients. Given the frequency of international travel, as well as the risk associated with recurrent outbreaks of foodborne illness from commercial food sources, it is important to recognize various syndromes of foodborne illness, including those which may require specific evaluation and management strategies. This article reviews a number of the most common causes of foodborne illness, as well as several less common pathogens with the potential for causing significant morbidity and mortality if not promptly identified and treated.

Botulism: cause, effects, diagnosis, clinical and laboratory identification, and treatment modalities

Botulism is a neuroparalytic disease caused by neurotoxins produced by the bacteria Clostridium botulinum. Botulinum neurotoxins (BoNTs) are among the most potent naturally occurring toxins and are a category A biological threat agent. The 7 toxin serotypes of BoNTs (serotypes A-G) have different toxicities, act through 3 different intracellular protein targets, and exhibit different durations of effect. Botulism may follow ingestion of food contaminated with BoNT, from toxin production of C botulinum present in the intestine or wounds, or from inhalation of aerosolized toxin. Intoxication classically presents as an acute, symmetrical, descending flaccid paralysis. Early diagnosis is important because antitoxin therapy is most effective when administered early. Confirmatory testing of botulism with BoNT assays or C botulinum cultures is time-consuming, and may be insensitive in the diagnosis of inhalational botulism and in as many as 32% of food-borne botulism cases. Therefore, the decision to initiate botulinum antitoxin therapy is primarily based on symptoms and physical examination findings that are consistent with botulism, with support of epidemiological history and electrophysiological testing. Modern clinical practice and antitoxin treatment has reduced botulism mortality rates from approximately 60% to < or =10%. The pentavalent botulinum toxoid is an investigational product and has been used for more than 45 years in at-risk laboratory workers to protect against toxin serotypes A to E. Due to declining immunogenicity and potency of the pentavalent botulinum toxoid, novel vaccine candidates are being developed.

Predicting CD4 lymphocyte count <200 cells/mm(3) in an HIV type 1-infected African population

Clinical criteria are recommended to select HIV-infected patients for initiation of antiretroviral therapy when CD4 lymphocyte testing is unavailable. We evaluated the performance characteristics of WHO staging criteria, anthropometrics, and simple laboratory measurements for predicting CD4 lymphocyte count (CD4 count) <200 cells/mm(3) among HIV-infected patients in Tanzania. A total of 202 adults, diagnosed with HIV infection through community-based testing, underwent a detailed evaluation including staging history and examination, anthropometry, complete blood count, erythrocyte sedimentation rate (ESR), and CD4 count. Univariable analysis and recursive partitioning were used to identify characteristics associated with CD4 count 200 cells/mm(3). Of 202 participants 109 (54%) had a CD4 count <200 cells/mm(3). Characteristics most strongly associated with CD4 count <200 cells/mm(3) (p-value <0.0001) were the presence of mucocutaneous manifestations (72% vs. 28%), lower total lymphocyte count (TLC) (median 1,450 vs. 2,200 cells/mm(3)), lower total white blood cell count (median 4,200 vs. 5,500 cells/mm(3)), and higher ESR (median 95 vs. 53 mm/h). In a partition tree model, TLC <1,200 cells/mm(3), ESR >or=120 mm/h, or the presence of mucocutaneous manifestations yielded a sensitivity of 0.85 and specificity of 0.63 for predicting CD4 count <200 cells/mm(3). The sensitivity of the 2006 WHO Staging system improved from 0.75 to 0.93 with inclusion of these parameters, at the expense of specificity (0.36 to 0.26). The presence of mucocutaneous manifestations, TLC <1,200 cells/mm(3), or ESR >or=120 mm/h was a strong predictor of CD4 count <200 cells/mm(3) and enhanced the sensitivity of the 2006 WHO staging criteria for identifying patients likely to benefit from antiretrovirals.

Long-Term Outcomes of 217 Botulism Cases in the Republic of Georgia

BACKGROUND

The acute paralytic syndrome of botulism has been well-described; however, little is known about its long-term consequences.

METHODS

We conducted a case-control study in the Republic of Georgia to evaluate the health of patients > or =6 months after they had experienced an episode of botulism. Case patients were selected on the basis of who had had a clinical diagnosis of foodborne botulism reported to the national surveillance system from 1998 through 2003. Three control subjects were randomly selected from each patient's community.

RESULTS

We located 217 patients who had had botulism from surveillance records, with a median time since onset of illness of 4.3 years. The median age was 37 years, and 49% of the patients were female, similar to the control subjects. Most of the patients (68%) had acquired botulism from home-conserved vegetables (probably containing toxin type B), 15% had been hospitalized for >1 month, and 25% had required mechanical ventilation. Six patients died. Of the remaining 211 patients, 68% reported having worse health at the time of the interview than 6 years before the interview, compared with 17% of 656 control subjects (matched odds ratio, 17.6; 95% confidence interval, 10.9-28.4). Overall, 49% of the patients reported their current health as "fair" or "poor," versus 25% of the control subjects (odds ratio, 5.0; 95% confidence interval, 3.2-7.6). Patients were more likely than control subjects to report fatigue, weakness, dizziness, dry mouth, and difficulty lifting objects (P<.05, for each). Patients were more likely than control subjects to report difficulty breathing caused by moderate exertion (P<.001) but not by minimal exertion or at rest. Patients were also more likely to report being limited in vigorous activities, walking 3 blocks, and climbing 3 flights of stairs (P<.05, for each). Finally, patients reported feeling significantly worse than control subjects for 6 of 11 questions regarding psychosocial well-being (P<.05, for each). In a multivariable model involving patients who had had botulism, mechanical ventilation during acute illness, older age, and region of residence independently predicted worse health.

CONCLUSIONS

Several years after acute botulism, patients reported significant health, functional, and psychosocial limitations that are likely to be consequences of the illness.

Chemical Terrorism Attacks: Update on Antidotes

There is well-founded concern that a chemical or radioactive agent will at some point be used as a weapon of terror. There are several antidotes that, if used correctly in a timely fashion, can help lessen the harm caused by these agents. This article is meant to introduce the clinician to several such agents, along with the antidotes useful in the management of exposure to these. It covers the indications, administration, and precautions for using these antidotes.

Food Poisoning

Food poisoning is encountered throughout the world. Many of the toxins responsible for specific food poisoning syndromes are no longer limited to isolated geographic locations. With increased travel and the ease of transporting food products, it is likely that a patient may present to any emergency department with the clinical effects of food poisoning. Recognizing specific food poisoning syndromes allows emergency health care providers not only to initiate appropriate treatment rapidly but also to notify health departments early and thereby prevent further poisoning cases. This article reviews several potential food-borne poisons and describes each agent's mechanism of toxicity, expected clinical presentation, and currently accepted treatment.

Foodborne botulism in the Republic of Georgia

In the Republic of Georgia, high rates of foodborne botulism are largely caused by home-preserved vegetables.

Foodborne botulism is a potentially fatal, paralytic illness that can cause large outbreaks. A possible increase in botulism incidence during 2001 in the Republic of Georgia prompted this study. We reviewed surveillance data and abstracted records of patients with botulism who were hospitalized from 1980 to 2002. During this period, 879 botulism cases were detected. The median annual incidence increased from 0.3 per 100,000 during 1980 to 1990 to 0.9 per 100,000 during 1991 to 2002. For 706 botulism patients hospitalized from 1980 to 2002, 80% of their cases were attributed to home-preserved vegetables. Surveillance evaluation verified that botulism incidence varied greatly by region. Georgia has the highest nationally reported rate of foodborne botulism in the world. A strategy addressing individual behaviors in the home is needed to improve food safety; developing this strategy requires a deeper understanding of why botulism has increased and varies by region.