Laboratory diagnostics of botulism

Could Intravenous Immunoglobulin Be an Alternative Therapy for Treating Infant Botulism in Areas Where Human Botulism Immunoglobulin Is Not Easily Available?: Our Experience in Andalusia, Spain

BACKGROUND

Infant botulism (IB) affects infants under 1 year of age, caused by the ingestion of Clostridium botulinum spores and subsequent neurotoxin production. IB is rare in Europe. This study aimed to analyze the epidemiology and management of IB over the past 25 years in Southern Spain.

METHODS

This is a retrospective, multicenter study of IB cases detected in Andalusia since 1997. Epidemiologic, clinical, diagnostic and outcome variables were analyzed.

RESULTS

Twenty-three patients from 7 different hospitals were included, with a median age of 3 months. Most of these patients presented with weak crying, constipation, arreactive mydriasis and loss of myotatic reflexes. Neurophysiological studies showed alterations in 74% of the cases at diagnosis. The diagnosis was confirmed in all cases by stool sample analysis. Only 4 patients received human botulism immunoglobulin (HBIG) and 10 received empirically intravenous immunoglobulin (IVIG). The median time to improvement in patients who received IVIG and HBIG was slightly shorter; however, no differences were observed. Significant differences were observed when IVIG was administered within the first 72 hours (14 vs. 25 days, P = 0.035). In addition, patients who received empirical antimicrobial therapy required longer hospitalization times secondary to observed exacerbated paralysis (20 vs. 12 days, P = 0.033).

CONCLUSIONS

IVIG may be an effective treatment for shortening the duration of illness in regions that are not readily accessible for HBIG, but further studies are needed. Although IB is rare, when it is suspected, antimicrobial therapy should be avoided as it may exacerbate paralysis by increasing the availability of neurotoxin for absorption.

Isolation of Clostridium botulinum type C from a wound in a pig

We report here the isolation of Clostridium botulinum type C from the medial muscles of the thigh of a gestating gilt with a claw wound and without evidence of septicemia. The pig died with paralytic signs, consistent with wound botulism, similar to episodes in humans.

Development and selection of candidate monoclonal antibodies for the detection of Clostridium botulinum neurotoxin serotype B light chain

Botulinum neurotoxin, produced by the bacterium Clostridium botulinum, causes botulism, a severe, rapidly progressing, and potentially fatal condition. Swift detection of the toxin and timely administration of antitoxin antibodies are critical for effective treatment. The current standard for Botulinum toxin testing is the mouse lethality assay, but this method is time-consuming and requires live animals. Consequently, a key focus of research is the development of antibodies for both diagnostic purposes and toxin neutralization. Botulinum neurotoxin serotype B (BoNT/B), one of the most dangerous and prevalent serotypes, is commonly involved in poisoning cases. Like other botulinum toxins, BoNT/B consists of heavy and light chains. In this study, we generated mouse monoclonal antibodies targeting the BoNT/B light chain (BoNT/B-LC) through hybridoma cell line development. Two monoclonal hybridomas (3B7 and 3C6) were selected from a pool of 18 polyclonal hybridomas and used to produce anti-BoNT/B-LC antibodies through the ascites fluid production. The antibodies were utilized for indirect ELISA detection of recombinant BoNT/B-LC. Notably, the assay with 3B7 demonstrated higher sensitivity, allowing for the detection of TrxA-fused BoNT/B-LC (68.9 kDa) at concentrations as low as 4 ng/mL. These results highlight the potential of the generated antibodies for rapid BoNT/B detection, offering a promising alternative to animal-based testing.

Dry and dusty outback: infant botulism

Infant botulism is a rare but life-threatening neuroparalytic syndrome caused by intestinal colonisation of Clostridium botulinum resulting in a symmetrical descending flaccid paralysis. This gram-positive, rod-shaped anaerobic bacillus is universally found in soil with previous links to ingestion of honey and dust contaminated with C. botulinum spores. We present a case of a baby boy with this rare condition eventually linked to dust on a rural outback property. This young patient was ventilated for 90 days. Initial serology for botulism toxin was negative, although C. botulinum spores were eventually grown in the stool. The patient did not receive early treatment with Human Botulism Immune Globulin Intravenous (BIG-IV) as there was a low index of suspicion and a delay in obtaining a stool sample for nearly 6 weeks due to constipation. This case highlights the importance of early treatment with BIG-IV when clinical features and environmental conditions in the remote Australian outback favour persistence of C. botulinum spores in soil without awaiting confirmatory tests.

Wearable Temperature Sensor Enhanced Volatilomics Technique for Swift and Convenient Detection of Latrogenic Botulism

Accurately assessing potential side effects following botulinum neurotoxin (BoNT) injection remains a formidable challenge. To address this issue, an innovative approach is developed that combines a wearable temperature sensor with a sophisticated volatilomics technique, aimed at facilitating the rapid and convenient prediction of potential physical discomfort related to latrogenic botulism. The investigation identifies five volatile organic compounds (VOCs)-acetone, styrene, ethanol, 2-pentanone, and n-butano-as promising markers indicative of BoNT poisoning. Specifically, a handheld breath analyzer, featuring a yttrium stabilized zirconia (YSZ)-based gas sensor array, alongside a wearable temperature sensor integrated with a bio-compatible methacrylated gelatin (GelMA) sensing film, are developed to simultaneously monitor breath signal variations and body temperature fluctuations. Preliminary animal testing validates the effectiveness of the integrated approach, achieving an accuracy exceeding 91.2% in early detection of physical discomfort associated with BoNT poisoning. These promising findings represent a significant advancement towards the early identification of BoNT-related issues, enabling timely intervention and improved management strategies.

The ionic liquid-assisted sample preparation method pTRUST allows sensitive proteome characterization of a variety of bacterial endospores to aid in the search for protein biomarkers

Bacterial endospores are ubiquitous and are responsible for various human infections. Recently, we reported that an ionic liquid (IL)-based sample preparation method (named pTRUST) facilitated highly efficient shotgun analysis of the Bacillus subtilis spore proteome in trace samples. In this study, we evaluated the efficiency and applicability of the pTRUST technology using three different spore preparations: one purified from the closely related subspecies B. subtilis natto and two from B. licheniformis and B. cereus. We showed that the pTRUST method allowed rapid solubilization and processing of all tested spore samples prepared for highly sensitive mass spectrometry (MS) analysis. Bioinformatics analysis using the BLAST program suggested that a set of 25 proteins commonly identified between the above three species and B. subtilis spores may be universal biomarkers among various bacterial species, including 43 spore-producing bacteria associated with industrial dairy processing environments and product spoilage. In contrast, the two identified proteins, D4FV94 in B. subtilis natto and Q737A2 in B. cereus, are likely species-specific biomarkers, because their orthologs are absent or rare in all organisms. The sensitivity and applicability of pTRUST, along with the putative protein biomarkers identified in this study, will facilitate a wide spectrum of spore research for biological and clinical applications.

Diagnosis of botulism in mammals aided by toxin ELISA and C and D gene RT-PCRs with an emphasis on farm animals

Animal welfare and ethical considerations limit the use of the mouse lethality bioassay for the detection of botulinum toxins. This study assessed an ELISA and RT-PCRs to detect toxin types C and D in samples from mammals with flaccid paralysis or weakness. DNA/RNA tightly bound to the toxin molecules were used as surrogates for the presence of toxin. In total 391 diverse samples from 101 clinical cases from cattle and 9 other species were examined. Botulism was confirmed by ELISA in samples from 16 cases. Toxin type C or D was identified by RT-PCR in 10 cases, five of which were among the cases confirmed by ELISA. Among the 80 cases with negative samples, sampling was not comprehensive enough in 66 cases (botulism therefore not excluded) but was adequate in 14 cases (no indication of botulism). The last two categories included 16 cases with other laboratory findings explaining the clinical signs. The ELISA that detects botulinum C and D toxins was superior in identifying cases with positive samples compared to the RT-PCRs but the latter were able to identify the toxin type present when positive. Furthermore, the RT-PCRs are available to any laboratory with molecular testing capability. Both laboratory assays can screen a comprehensive range and a large number of samples which is crucial for a successful diagnosis of botulism.

Development of a loop-mediated isothermal amplification method for the rapid detection of Clostridium botulinum serotypes E and F

BACKGROUND

Botulinum neurotoxin serotypes E and F (BoNT/E and BoNT/F) produced by the bacteria Clostridium botulinum (C. botulinum) found in a wide variety of foods cause poisoning in humans with high mortality rates. Mouse bioassays (MBAs), the gold standard method for BoNT detection, have a low detection limit; however, require experienced personnel and take a long time to obtain results. Therefore, it has been gradually replaced by nucleic acid amplification tests (NAATs) with primers targeting species-specific genes.

METHODS AND RESULTS

In this study, for each serotype E and F, six LAMP primers were designed based on multiple sequence alignments of the conserved regions of the bont/E and bont/F genes collected from 180 serotype E strains and 23 serotype F strains published in NCBI. In silico PCR amplification with the outer primer pairs showed successful amplification of the target fragments. To validate the LAMP method, we constructed two synthetic plasmids containing the target sequences extended approximately 10-50 bp to both ends. The specificity of the primers was further evaluated using six different Clostridium species and eight strains belonging to other common food poisoning-related bacterial species. Employing the synthetic plasmids, the optimal temperatures and limits of detection (LODs) were determined for bont/E (63 °C, LOD ≤ 101 copies/reaction) and bont/F (65 °C, LOD ≤ 102 copies/reaction) within 30 min. In addition, the LAMP primer set for BoNT/F was redesigned with degenerate nucleotides that improved the coverage from 15 to 45%.

CONCLUSIONS

For future directions, applications of the established method, especially with the degenerate primers, could be used as an alternative assay for the rapid and sensitive detection of C. botulinum.

Neuromuscular junction disorders: mimics and chameleons

Neuromuscular junction (NMJ) disorders represent a heterogenous group of acquired and congenital disorders that present in variable and distinctive ways. The diagnosis is typically reached through a combination of clinical, serological, pharmacological and electrophysiological evaluation. While the diagnosis can be fairly straightforward in some cases, the overlap with other neurological disorders can make diagnosis challenging, particularly in pure ocular presentations and in seronegative patients. The over-reliance on serological tests and electrophysiological evaluation in isolation can lead to misdiagnosis. In this article, we provide an overview of the NMJ disorders, discuss red flags for the key differential diagnoses (mimics) and report the atypical ways in which NMJ disorders may present (chameleons).

An outbreak of botulism on a pig farm due to the newly described Clostridium botulinum type C

This study reports a botulism outbreak on a pig farm. Clostridium botulinum type C was detected using PCR. The gene encoding the toxin corresponds to a novel type C neurotoxin recently described in a human botulism outbreak, raising the question of its prevalence in pigs and the related risks to humans.

A neonatal mouse model of meconium peritonitis generated using human meconium slurry

BACKGROUND

Meconium peritonitis is a noninfectious chemical peritonitis that occurs following fetal intestinal perforation and leakage of meconium into the abdominal cavity. Because of the lack of appropriate animal models, its pathophysiology has not yet been elucidated. We aimed to create a neonatal mouse model of meconium peritonitis using human meconium slurry (MS).

METHODS

A stock MS solution prepared from fresh meconium obtained from healthy term infants was administered intraperitoneally to 4-d-old newborn mice. An MS LD40 was then administered, and changes in body weight, hematology, serum biochemistry, and immunomodulatory gene expression were determined. The MS was subjected to antibiotic treatment and heat inactivation to validate the content. Finally, comparisons with nonsurgical neonatal sepsis mouse models were performed.

RESULTS

Dose-dependent mortality rates were observed, with an LD40 of 200 µL/body weight established. Substantial hematological and hepatorenal abnormalities and increased inflammatory gene expression were observed. Although antibiotic treatment was ineffective, the survival rate was improved by enzymatic inactivation of MS. Importantly, the systemic responses to MS were distinct from those observed in neonatal sepsis model mice.

CONCLUSION

The MS model closely reflects the pathology of human neonatal meconium peritonitis and maybe useful in research elucidating the pathophysiology of this condition.

IMPACT

In this study, we generated a neonatal mouse model of meconium peritonitis through intraperitoneal administration of human meconium slurry. We clarified that the pathogenic agent in meconium slurry is mainly a digestive enzyme, and that the systemic responses elicited by meconium slurry were distinct from those in a neonatal sepsis mouse model. As our mouse model is simple and highly reproducible, it is useful for elucidating the pathophysiology of meconium peritonitis.

Selection of Candidate Monoclonal Antibodies for Therapy of Botulinum Toxin Type A Intoxications

Botulism is one of the most serious food intoxications, manifesting as prolonged paralytic conditions. This disease is usually the result of the consumption of poor quality canned or smoked foods, so the inhabitants of many countries of the world are exposed to the risk of this kind of poisoning every year. In view of the severity of poisonings caused by botulinum neurotoxins, monoclonal antibodies (mAbs) show great promise because of their targeting action, lack of allergic reactions and serum sickness. The use of a cocktail of mAbs increases the "functional specificity" of their mixture, allowing them to bind to the active domains of different toxin chains and block their action. In this work, we obtained 14 murine mAbs to the catalytic and receptor-binding domain of botulinum toxin type A. The Sp2/0-Ag14 murine myeloma cell line and splenocytes from immunized mice of the BALB/c line were used as fusion partners. We have shown that the selected cocktail of three antibodies neutralizes native toxin more effectively than antibodies separately-complete neutralization is achieved at a toxin dose of 3LD50 and partial neutralization at 5LD50. We presume that this cocktail may be promising as a prototype for the creation of a therapeutic drug capable of neutralizing the toxin in the blood of patients.

The Usefulness of Salivary Gland Organoids for Evaluation of the Potency of Botulinum Neurotoxin

BACKGROUND AND OBJECTIVES

Botulinum neurotoxin (BoNT) is a substance used to treat chronic sialorrhea, muscle dystonia, and is used in cosmetic applications. Measuring the potency of BoNT is crucial because it acts even with a small amount. However, the current methods for measuring the potency of BoNT involve using two-dimensional neuroblastoma cell line-based methods. In this study, we aimed to develop a new method to measure the potency of BoNT using a three-dimensional organoid culture system.

MATERIALS AND METHOD

We established the optimal conditions for coculturing N2a neuronal cells with murine salivary gland organoids (SGOs). After determining the appropriate chemical concentrations, we treated the SGOs cocultured with N2a cells with BoNT type A (BoNT/A). We confirmed the expression of salivary gland-related genes and proteins using real-time polymerase chain reaction (PCR) and immunofluorescence staining.

RESULTS

The SGOs cocultured with N2a cells showed that the dendrites or axons of neuronal cells were in contact with the outermost layer of the SGOs. When we applied acetylcholine and neostigmine to the coculture systems, the mRNA expression of Aqp5 and Bhlha15, associated with salivary gland secretory cells, increased. However, this effect was reversed when BoNT/A was applied, as confirmed through real-time PCR.

CONCLUSION

We found that the coculture system of SGOs and N2a neuronal cells can potentially serve as a potency testing platform for BoNT.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:2697-2704, 2024.

Case report: Aberrant fecal microbiota composition of an infant diagnosed with prolonged intestinal botulism

BACKGROUND

Intestinal botulism is primarily reported in small babies as a condition known as infant botulism. The condition results from the ingestion of environmental or foodborne spores of botulinum neurotoxin (BoNT) producing Clostridia, usually Clostridium botulinum, and subsequent spore germination into active botulinum neurotoxinogenic cultures in the gut. It is generally considered that small babies are susceptible to C. botulinum colonization because of their immature gut microbiota. Yet, it is poorly understood which host factors contribute to the clinical outcome of intestinal botulism. We previously reported a case of infant botulism where the infant recovered clinically in six weeks but continued to secrete C. botulinum cells and/or BoNT in the feces for seven months.

CASE PRESENTATION

To further understand the microbial ecology behind this exceptionally long-lasting botulinum neurotoxinogenic colonization, we characterized the infant fecal microbiota using 16S rRNA gene amplicon sequencing over the course of disease and recovery. C. botulinum could be detected in the infant fecal samples at low levels through the acute phase of the disease and three months after recovery. Overall, we observed a temporal delay in the maturation of the infant fecal microbiota associated with a persistently high-level bifidobacterial population and a low level of Lachnospiraceae, Bacteroidaceae and Ruminococcaceae compared to healthy infants over time.

CONCLUSION

This study brings novel insights into the infant fecal composition associated with intestinal botulism and provides a basis for a more systematic analysis of the gut microbiota of infants diagnosed with botulism. A better understanding of the gut microbial ecology associated with infant botulism may support the development of prophylactic strategies against this life-threatening disease in small babies.

Aminopyridines Restore Ventilation and Reverse Respiratory Acidosis at Late Stages of Botulism in Mice

Botulinum neurotoxin (BoNT) is a potent protein toxin that causes muscle paralysis and death by asphyxiation. Treatments for symptomatic botulism are intubation and supportive care until respiratory function recovers. Aminopyridines have recently emerged as potential treatments for botulism. The clinically approved drug 3,4-diaminopyridine (3,4-DAP) rapidly reverses toxic signs of botulism and has antidotal effects when continuously administered in rodent models of lethal botulism. Although the therapeutic effects of 3,4-DAP likely result from the reversal of diaphragm paralysis, the corresponding effects on respiratory physiology are not understood. Here, we combined unrestrained whole-body plethysmography (UWBP) with arterial blood gas measurements to study the effects of 3,4-DAP, and other aminopyridines, on ventilation and respiration at terminal stages of botulism in mice. Treatment with clinically relevant doses of 3,4-DAP restored ventilation in a dose-dependent manner, producing significant improvements in ventilatory parameters within 10 minutes. Concomitant with improved ventilation, 3,4-DAP treatment reversed botulism-induced respiratory acidosis, restoring blood levels of CO2, pH, and lactate to normal physiologic levels. Having established that 3,4-DAP-mediated improvements in ventilation were directly correlated with improved respiration, we used UWBP to quantitatively evaluate nine additional aminopyridines in BoNT/A-intoxicated mice. Multiple aminopyridines were identified with comparable or enhanced therapeutic efficacies compared with 3,4-DAP, including aminopyridines that selectively improved tidal volume versus respiratory rate and vice versa. In addition to contributing to a growing body of evidence supporting the use of aminopyridines to treat clinical botulism, these data lay the groundwork for the development of aminopyridine derivatives with improved pharmacological properties. SIGNIFICANCE STATEMENT: There is a critical need for fast-acting treatments to reverse respiratory paralysis in patients with botulism. This study used unrestrained, whole-body plethysmography and arterial blood gas analysis to show that aminopyridines rapidly restore ventilation and respiration and reverse respiratory acidosis when administered to mice at terminal stages of botulism. In addition to supporting the use of aminopyridines as first-line treatments for botulism symptoms, these data are expected to contribute to the development of new aminopyridine derivatives with improved pharmacological properties.

Pathogenicity and virulence of Clostridium botulinum

Clostridium botulinum, a polyphyletic Gram-positive taxon of bacteria, is classified purely by their ability to produce botulinum neurotoxin (BoNT). BoNT is the primary virulence factor and the causative agent of botulism. A potentially fatal disease, botulism is classically characterized by a symmetrical descending flaccid paralysis, which is left untreated can lead to respiratory failure and death. Botulism cases are classified into three main forms dependent on the nature of intoxication; foodborne, wound and infant. The BoNT, regarded as the most potent biological substance known, is a zinc metalloprotease that specifically cleaves SNARE proteins at neuromuscular junctions, preventing exocytosis of neurotransmitters, leading to muscle paralysis. The BoNT is now used to treat numerous medical conditions caused by overactive or spastic muscles and is extensively used in the cosmetic industry due to its high specificity and the exceedingly small doses needed to exert long-lasting pharmacological effects. Additionally, the ability to form endospores is critical to the pathogenicity of the bacteria. Disease transmission is often facilitated via the metabolically dormant spores that are highly resistant to environment stresses, allowing persistence in the environment in unfavourable conditions. Infant and wound botulism infections are initiated upon germination of the spores into neurotoxin producing vegetative cells, whereas foodborne botulism is attributed to ingestion of preformed BoNT. C. botulinum is a saprophytic bacterium, thought to have evolved its potent neurotoxin to establish a source of nutrients by killing its host.

Adult-onset botulism in a Japanese woman with prolonged spore excretion

We report a case of an 80-year-old woman with botulism from 2020 in Osaka, Japan. The patient complained of dysarthria and dizziness. On the same day, the patient developed respiratory failure, and was intubated and placed on mechanical ventilation. Subsequently, ophthalmoparesis and quadriparesis progressed rapidly. Ten days after onset, the patient failed to respond to any external stimulation. Blood tests showed anemia, and computed tomography revealed undiagnosed cervical cancer. Initially, diagnosis of neuromuscular junction disorder and acute motor neuropathy, including paraneoplastic syndrome, were considered. However, intravenous immunoglobulin therapy and plasma exchange were ineffective. A fecal sample on day 30 showed a large number of C. botulinum spores. On day 34, a mouse bioassay revealed botulinum toxin type A in the patient's serum; therefore, a botulinum antitoxin was administered. Later, the patient's muscle strength was gradually improved. However, severe muscle paralysis persisted, and the patient died of cachexia owing to cervical cancer on day 196. The etiology of this case was unknown because no contaminated food was identified during an inspection of the patient's home. Fecal 16S rRNA gene sequencing revealed dysbiosis of the intestinal microbiota with abundant Enterococcus species. Long-lasting excretion of substantial botulinum spores even on day 30 indicated colonization of C. botulinum in the intestinal tract. This case suggests that C. botulinum colonization with co-existing intestinal dysbiosis may be associated with severe and prolonged symptoms of botulism.

Exploring the genetic background of the botulism neurotoxin BoNT/B2 in Spain

To determine whether the neurotoxin BoNT/B2 causing botulism in Spain is clonal, the genetic diversity and phylogenetic relationships of Clostridium botulinum from food-borne episodes and infant cases of the condition were explored. The botulinum toxin gene (bont) subtype, the variable region of the flagellin gene (flaVR), and a seven-gene multi-locus sequence type were examined by sequencing 37 BoNT-positive cultures obtained over the period 2010 to 2022. Out of 37 botulism events, 16 food-borne episodes and 16 infant cases were associated with bont/b2. Eight bont/b2 alleles were detected [nucleotide distance range 0.0259-0.415%, Hunter and Gaston discrimination index (HGDI) 0.71]. The most common bont/b2 allele corresponded to that of strain Prevot 25 NCASE and its single and double locus variations (87.5%). Four known flaVR types were identified (HGDI 0.79), along with one previously unknown (flaVR-15). Sixteen sequence types (STs) (HGDI 0.89) were recorded including seven new STs (ST164-ST170; 10 new alleles) and five new STs (ST171-ST175; with new allele combinations) were also noted. Correlations among some STs and flaVR types were seen. Overall, the present results show that the combined analysis of bont/b2-flaVR-ST at the nucleotide level could be used to track botulism events in Spain. The neurotoxin BoNT/B2 has largely been responsible for human botulism in Spain. The polymorphism analysis of bont/b2, flaVR typing, and sequence type determinations, revealed a wide variety of clones to be responsible for human botulism, ruling out a common source of acquisition. IMPORTANCE Botulism, a potentially fatal disease, is classically characterized by a symmetrical descending flaccid paralysis, which if left untreated can lead to respiratory failure and death. Botulinum neurotoxin (BoNT), produced by certain species of Clostridium, is the most potent biological toxin known, and the direct cause of botulism. This study characterizes the acquisition in Spain of two forms of botulism, i.e., food-borne and infant botulism, which are largely caused by the main neurotoxin BoNT/B2. Polymorphism analysis of the bont/b2 gene, typing of the flagellin variable region sequence (flaVR), and multilocus sequence typing, were used to explore the genetic background of Clostridium botulinum group I. To our knowledge, this is the first phylogenetic and typing study of botulism undertaken in Spain.

MicroRNA therapeutics and nucleic acid nano-delivery systems in bacterial infection: a review

Bacteria that have worked with humans for thousands of years pose a major threat to human health even today, as drug resistance has become a prominent problem. Compared to conventional drug therapy, nucleic acid-based therapies are a promising and potential therapeutic strategy for diseases in which nucleic acids are delivered through a nucleic acid delivery system to regulate gene expression in specific cells, offering the possibility of curing intractable diseases that are difficult to treat at this stage. Among the many nucleic acid therapeutic ideas, microRNA, a class of small nucleic acids with special properties, has made great strides in biology and medicine in just over two decades, showing promise in preclinical drug development. In this review, we introduce recent advances in nucleic acid delivery systems and their clinical applications, highlighting the potential of nucleic acid therapies, especially miRNAs extracted from traditional herbs, in combination with the existing set of nucleic acid therapeutic systems, to potentially open up a new line of thought in the treatment of cancer, viruses, and especially bacterial infectious diseases.

Molecular Diversity of BoNT-Producing Clostridia—A Still-Emerging and Challenging Problem

The diversity of BoNT-producing Clostridia is still a worrying problem for specialists who explore the evolutionary and taxonomic diversity of C. botulinum. It is also a problem for epidemiologists and laboratory staff conducting investigations into foodborne botulism in humans and animals, because their genetic and phenotypic heterogeneity cause complications in choosing the proper analytical tools and in reliably interpreting results. Botulinum neurotoxins (BoNTs) are produced by several bacterial groups that meet all the criteria of distinct species. Despite this, the historical designation of C. botulinum as the one species that produces botulinum toxins is still exploited. New genetic tools such as whole-genome sequencing (WGS) indicate horizontal gene transfer and the occurrence of botulinum gene clusters that are not limited only to Clostridium spp., but also to Gram-negative aerobic species. The literature data regarding the mentioned heterogeneity of BoNT-producing Clostridia indicate the requirement to reclassify C. botulinum species and other microorganisms able to produce BoNTs or possessing botulinum-like gene clusters. The aim of this study was to present the problem of the diversity of BoNT-producing Clostridia over time and new trends toward obtaining a reliable classification of these microorganisms, based on a complex review of the literature.

Crystal structures of OrfX1, OrfX2 and the OrfX1-OrfX3 complex from the orfX gene cluster of botulinum neurotoxin E1

Botulinum neurotoxins (BoNTs) are among the most lethal toxins known to humans, comprising seven established serotypes termed BoNT/A-G encoded in two types of gene clusters (ha and orfX) in BoNT-producing clostridia. The ha cluster encodes four non-toxic neurotoxin-associated proteins (NAPs) that assemble with BoNTs to protect and enhance their oral toxicity. However, the structure and function of the orfX-type NAPs remain largely unknown. Here, we report the crystal structures for OrfX1, OrfX2, and an OrfX1-OrfX3 complex, which are encoded in the orfX cluster of a BoNT/E1-producing Clostridium botulinum strain associated with human foodborne botulism. These structures lay the foundation for future studies on the potential roles of OrfX proteins in oral intoxication and pathogenesis of BoNTs.

Infant Botulism, Israel, 2007-2021

Infant botulism (IB) is an intestinal toxemia that manifests as descending paralysis, constipation, and, in some cases, respiratory failure. Laboratory-confirmed IB cases are rare, and recent data in Israel are lacking. We conducted a national multicenter retrospective study of laboratory-confirmed IB cases reported in Israel during 2007-2021. A total of 8 cases were reported during the study period. During 2019-2021, incidence may have increased because of a cluster of 5 cases. Infant median age for diagnosis was 6.5 months, older than previously reported (3 months). Most cases occurred during March-July. Honey consumption was reported in 1 case, and possible environmental risk factors (living nearby rural or construction areas, dust exposure, and having a father who works as a farmer) were reported in 6 cases. Although IB is rare, its incidence in Israel may have increased over recent years, and its epidemiology and risk factors differ from cases reported previously in Israel.

Single-domain antibody delivery using an mRNA platform protects against lethal doses of botulinum neurotoxin A

Single-domain antibodies (sdAbs, VHHs, or nanobodies) are a promising tool for the treatment of both infectious and somatic diseases. Their small size greatly simplifies any genetic engineering manipulations. Such antibodies have the ability to bind hard-to-reach antigenic epitopes through long parts of the variable chains, the third complementarity-determining regions (CDR3s). VHH fusion with the canonical immunoglobulin Fc fragment allows the Fc-fusion single-domain antibodies (VHH-Fc) to significantly increase their neutralizing activity and serum half-life. Previously we have developed and characterized VHH-Fc specific to botulinum neurotoxin A (BoNT/A), that showed a 1000-fold higher protective activity than monomeric form when challenged with five times the lethal dose (5 LD₅₀) of BoNT/A. During the COVID-19 pandemic, mRNA vaccines based on lipid nanoparticles (LNP) as a delivery system have become an important translational technology that has significantly accelerated the clinical introduction of mRNA platforms. We have developed an mRNA platform that provides long-term expression after both intramuscular and intravenous application. The platform has been extensively characterized using firefly luciferase (Fluc) as a reporter. An intramuscular administration of LNP-mRNA encoding VHH-Fc antibody made it possible to achieve its rapid expression in mice and resulted in 100% protection when challenged with up to 100 LD₅₀ of BoNT/A. The presented approach for the delivery of sdAbs using mRNA technology greatly simplifies drug development for antibody therapy and can be used for emergency prophylaxis.

Botulism in Spain: Epidemiology and Outcomes of Antitoxin Treatment, 1997-2019

BACKGROUND

Botulism is a low incidence but potentially fatal infectious disease caused by neurotoxins produced mainly by Clostridium botulinum. There are different routes of acquisition, food-borne and infant/intestinal being the most frequent presentation, and antitoxin is the treatment of choice in all cases. In Spain, botulism is under surveillance, and case reporting is mandatory.

METHODS

This retrospective study attempts to provide a more complete picture of the epidemiology of botulism in Spain from 1997 to 2019 and an assessment of the treatment, including the relationship between a delay in antitoxin administration and the length of hospitalization using the Cox proportional hazards test and Kruskal-Wallis test, and an approach to the frequency of adverse events, issues for which no previous national data have been published.

RESULTS

Eight of the 44 outbreaks were associated with contaminated commercial foods involving ≤7 cases/outbreak; preserved vegetables were the main source of infection, followed by fish products; early antitoxin administration significantly reduces the hospital stay, and adverse reactions to the antitoxin affect around 3% of treated cases.

A 43-Day-Old Male With Respiratory Distress and Acute-Onset Hypotonia

A 43-day-old, full-term, previously healthy male presented with decreased activity and oral intake. He was found to be grunting and hypoxemic on examination, and a respiratory pathogen panel was positive for rhinovirus. He was diagnosed with presumed bronchiolitis. His neurologic exam on admission was normal. Because of respiratory failure, he was escalated from high-flow nasal cannula to bilevel positive airway pressure upon admission and he was started on ceftriaxone and vancomycin while awaiting culture data. On hospital day 6, he required escalation of respiratory support. His examination at that time was notable for new hypotonia of his bilateral upper and lower extremities, sluggish pupils, bilateral exotropia, intermittent vertical nystagmus, and an absent Moro reflex. He developed a focal seizure and a computed tomography of the brain demonstrated simple right otomastoiditis. The seizure was attributed to a serum sodium of 113 mmol/L in the setting of syndrome of inappropriate antidiuretic hormone secretion, thought to be secondary to viral bronchiolitis. However, as the patient's sodium was corrected to a normal range, he continued to have neurologic deficits on examination. Given his persistent hypotonia and respiratory failure, atypical for the expected course of viral bronchiolitis, the patient underwent an extensive neurologic and infectious workup, which ultimately revealed a surprising diagnosis.

High-pressure pasteurization of low-acid chilled ready-to-eat food

The working population growth have created greater consumer demand for ready-to-eat (RTE) foods. Pasteurization is one of the most common preservation methods for commercial production of low-acid RTE cold-chain products. Proper selection of a pasteurization method plays an important role not only in ensuring microbial safety but also in maintaining food quality during storage. Better retention of flavor, color, appearance, and nutritional value of RTE products is one of the reasons for the food industry to adopt novel technologies such as high-pressure processing (HPP) as a substitute or complementary technology for thermal pasteurization. HPP has been used industrially for the pasteurization of high-acid RTE products. Yet, this method is not commonly used for pasteurization of low-acid RTE food products, due primarily to the need of additional heating to thermally inactivate spores, coupled with relatively long treatment times resulting in high processing costs. Practical Application: Food companies would like to adopt novel technologies such as HPP instead of using conventional thermal processes, yet there is a lack of information on spoilage and the shelf-life of pasteurized low-acid RTE foods (by different novel pasteurization methods including HPP) in cold storage. This article provides an overview of the microbial concerns and related regulatory guidelines for the pasteurization of low-acid RTE foods and summarizes the effects of HPP in terms of microbiology (both pathogens and spoilage microorganisms), quality, and shelf-life on low-acid RTE foods. This review also includes the most recent research articles regarding a comparison between HPP pasteurization and thermal pasteurization treatments and the limitations of HPP for low-acid chilled RTE foods.

rAAV expressing recombinant neutralizing antibody for the botulinum neurotoxin type A prophylaxis

Botulinum neurotoxin (BoNT) is one of the most dangerous bacterial toxins and a potential biological weapon component. BoNT mechanism of pathological action is based on inhibiting the release of neurotransmitters from nerve endings. To date, anti-BoNT therapy is reduced to the use of horse hyperimmune serum, which causes many side effects, as well as FDA-approved drug BabyBig which consists of human-derived anti-BoNT antibodies (IgG) for infant botulinum treatment. Therapeutics for botulism treatment based on safer monoclonal antibodies are undergoing clinical trials. In addition, agents have been developed for the specific prevention of botulism, but their effectiveness has not been proved. In this work, we have obtained a recombinant adeno-associated virus (rAAV-B11-Fc) expressing a single-domain antibody fused to the human IgG Fc-fragment (B11-Fc) and specific to botulinum toxin type A (BoNT/A). We have demonstrated that B11-Fc antibody, expressed via rAAV-B11-Fc treatment, can protect animals from lethal doses of botulinum toxin type A, starting from day 3 and at least 120 days after administration. Thus, our results showed that rAAV-B11-Fc can provide long-term expression of B11-Fc-neutralizing antibody in vivo and provide long-term protection against BoNT/A intoxication. Consequently, our study demonstrates the applicability of rAAV expressing protective antibodies for the prevention of intoxication caused by botulinum toxins.

Genomic Diversity, Competition, and Toxin Production by Group I and II Clostridium botulinum Strains Used in Food Challenge Studies

Botulinum neurotoxins (BoNTs) produced by the bacteria Clostridium botulinum are the causative agent of human and animal botulism, a rare but serious and potentially deadly intoxication. Foodborne botulism is caused by the consumption of foods containing BoNTs, which results from contamination of foods with C. botulinum spores and toxin production by the bacteria during growth within the food. Validation of the safety of food products is essential in preventing foodborne botulism, however, limited guidance and standards exist for the selection of strains used in C. botulinum food challenge studies. Sequencing and genomics studies have revealed that C. botulinum is a large, diverse, and polyphyletic species, with physiologic and growth characteristics studied only in a few representatives. Little is known about potential growth competition or effects on toxin production between C. botulinum strains. In this study, we investigated an applied cocktail of ten C. botulinum strains, seven Group I and three Group II. Whole genome SNP alignments revealed that this strain cocktail encompasses the major clades of the Group I and II C. botulinum species. While growth competition appears to exist between several of the strains, the cocktail as a whole resulted in high levels of BoNT production.

Major pathogenic Clostridia in human and progress toward the clostridial vaccines

The Clostridium genus is composed of a large spectrum of heterogeneous bacteria. They are Gram-positive, mostly mesophilic, and anaerobic spore-forming strains. Clostridia are widely distributed in oxygen-free habitats. They are found principally in the soil and intestines of ruminants as normal flora, but also are the cause of several infections in humans. The infections produced by important species in humans include botulism, tetanus, pseudomembranous colitis, antibiotics-associated diarrhea, and gas gangrene. Immunization with toxoid or bacterin-toxoid or genetically modified or other vaccines is a protective way against clostridial infection. Several experimental or commercial vaccines have been developed worldwide. Although conventional vaccines including toxoid vaccines are very important, the new generation of vaccines is an effective alternative to conventional vaccines. Recent advances have made it possible for new vaccines to increase immunogenicity. This review discusses briefly the important species of clostridia in humans, their toxins structure, and vaccine development and usage throughout the world.

Comparative whole-genome sequence analysis of a BoNT/B5-producing Clostridium botulinum isolate from an infant botulism case of unknown source in Osaka, Japan

A case of infant botulism of unknown origin, not involved in honey consumption, occurred in Osaka, Japan in 2020. A Clostridium botulinum type B strain named Osaka2020 was isolated from a stool sample of the patient. To clarify the epidemiology of the case, we performed whole-genome sequencing (WGS) of the isolate and compared it with strains from other sources. WGS analysis revealed that isolate Osaka2020 was classified into ST133 of a new sequence type, B5 subtype, and its toxin gene was encoded in a ∼274 kb plasmid. This plasmid was closely related to the pCLJ plasmid from strain 657Ba in the USA, reported to be conjugatively transferable to other strains. Moreover, isolate Osaka2020 also possesses another smaller plasmid that was common with some type A(B) infant botulism isolates in Japan. The phylogenetic tree from whole-genome SNP analysis showed that isolate Osaka2020 was the most closely related to a type B infant botulism isolate that occurred in Japan 10 years ago. Although no epidemiological connection among the two cases was confirmed, there is possibility that the cases are attributed to common causes such as some environmental substance.

Specific Isolation of Clostridium botulinum Group I Cells by Phage Lysin Cell Wall Binding Domain with the Aid of S-Layer Disruption

Clostridium botulinum is a notorious pathogen that raises health and food safety concerns by producing the potent botulinum neurotoxin and causing botulism, a potentially fatal neuroparalytic disease in humans and animals. Efficient methods for the identification and isolation of C. botulinum are warranted for laboratory diagnostics of botulism and for food safety risk assessment. The cell wall binding domains (CBD) of phage lysins are recognized by their high specificity and affinity to distinct types of bacteria, which makes them promising for the development of diagnostic tools. We previously identified CBO1751, which is the first antibotulinal phage lysin showing a lytic activity against C. botulinum Group I. In this work, we assessed the host specificity of the CBD of CBO1751 and tested its feasibility as a probe for the specific isolation of C. botulinum Group I strains. We show that the CBO1751 CBD specifically binds to C. botulinum Group I sensu lato (including C. sporogenes) strains. We also demonstrate that some C. botulinum Group I strains possess an S-layer, the disruption of which by an acid glycine treatment is required for efficient binding of the CBO1751 CBD to the cells of these strains. We further developed CBO1751 CBD-based methods using flow cytometry and magnetic separation to specifically isolate viable cells of C. botulinum Group I. These methods present potential for applications in diagnostics and risk assessment in order to control the botulism hazard.

Antidotal treatment of botulism in rats by continuous infusion with 3,4-diaminopyridine

Botulinum neurotoxins (BoNTs) are highly potent, select agent toxins that inhibit neurotransmitter release at motor nerve terminals, causing muscle paralysis and death by asphyxiation. Other than post-exposure prophylaxis with antitoxin, the only treatment option for symptomatic botulism is intubation and supportive care until recovery, which can require weeks or longer. In previous studies, we reported the FDA-approved drug 3,4-diaminopyridine (3,4-DAP) reverses early botulism symptoms and prolongs survival in lethally intoxicated mice. However, the symptomatic benefits of 3,4-DAP are limited by its rapid clearance. Here we investigated whether 3,4-DAP could sustain symptomatic benefits throughout the full course of respiratory paralysis in lethally intoxicated rats. First, we confirmed serial injections of 3,4-DAP stabilized toxic signs and prolonged survival in rats challenged with 2.5 LD50 BoNT/A. Rebound of toxic signs and death occurred within hours after the final 3,4-DAP treatment, consistent with the short half-life of 3,4-DAP in rats. Based on these data, we next investigated whether the therapeutic benefits of 3,4-DAP could be sustained throughout the course of botulism by continuous infusion. To ensure administration of 3,4-DAP at clinically relevant doses, three infusion dose rates (0.5, 1.0 and 1.5 mg/kg∙h) were identified that produced steady-state serum levels of 3,4-DAP consistent with clinical dosing. We then compared dose-dependent effects of 3,4-DAP on toxic signs and survival in rats intoxicated with 2.5 LD50 BoNT/A. In contrast to saline vehicle, which resulted in 100% mortality, infusion of 3,4-DAP at ≥ 1.0 mg/kg∙h from 1 to 14 d after intoxication produced 94.4% survival and full resolution of toxic signs, without rebound of toxic signs after infusion was stopped. In contrast, withdrawal of 3,4-DAP infusion at 5 d resulted in re-emergence of toxic sign and death within 12 h, confirming antidotal outcomes require sustained 3,4-DAP treatment for longer than 5 d after intoxication. We exploited this novel survival model of lethal botulism to explore neurophysiological parameters of diaphragm paralysis and recovery. While neurotransmission was nearly eliminated at 5 d, neurotransmission was significantly improved at 21 d in 3,4-DAP-infused survivors, although still depressed compared to naïve rats. 3,4-DAP is the first small molecule to reverse systemic paralysis and promote survival in animal models of botulism, thereby meeting a critical treatment need that is not addressed by post-exposure prophylaxis with conventional antitoxin. These data contribute to a growing body of evidence supporting the use of 3,4-DAP to treat clinical botulism.

Animal botulism in Poland – laboratory and epidemiological investigations

Introduction

The aim of the study was to present cases of botulism in animals found in Poland in 2019–2021. The analytical laboratory diagnosis and difficulties that occurred in the interpretation of the results are described.

Material and Methods

From 2019 to 2021, samples of serum, intestinal content, liver, spleen, kidney, faeces, wet feed, dry feed, ensilage, water and mixed samples of internal organs associated with 10 suspected animal botulism cases were sent to the National Veterinary Research Institute. Samples were analysed using a mouse bioassay and culture methods in combination with ntnh and bont gene detection.

Results

Among the ten putative botulism cases, only four (40%) were confirmed in the laboratory on the basis of the detection of botulinum toxin (BoNT) or the ntnh or bont genes. The remaining six (60%) were determined as probable despite observable characteristic clinical signs.

Conclusion

The diagnosis of botulism in animals is a very difficult task, made so by the heterogeneity of Clostridium botulinum strains and possible loss of toxinogenicity during laboratory processing or the potential degradation of toxins. Laboratory diagnosis is a complex and problematic process which should utilise different prescribed methods for specific types of sample.

Sporulation Strategies and Potential Role of the Exosporium in Survival and Persistence of Clostridium botulinum

Clostridium botulinum produces the botulinum neurotoxin that causes botulism, a rare but potentially lethal paralysis. Endospores play an important role in the survival, transmission, and pathogenesis of C. botulinum. C. botulinum strains are very diverse, both genetically and ecologically. Group I strains are terrestrial, mesophilic, and produce highly heat-resistant spores, while Group II strains can be terrestrial (type B) or aquatic (type E) and are generally psychrotrophic and produce spores of moderate heat resistance. Group III strains are either terrestrial or aquatic, mesophilic or slightly thermophilic, and the heat resistance properties of their spores are poorly characterized. Here, we analyzed the sporulation dynamics in population, spore morphology, and other spore properties of 10 C. botulinum strains belonging to Groups I–III. We propose two distinct sporulation strategies used by C. botulinum Groups I–III strains, report their spore properties, and suggest a putative role for the exosporium in conferring high heat resistance. Strains within each physiological group produced spores with similar characteristics, likely reflecting adaptation to respective environmental habitats. Our work provides new information on the spores and on the population and single-cell level strategies in the sporulation of C. botulinum.

Epidemiology of botulism in the north-western Romania-a 7-year survey

Botulism is a rare, acute, life-threatening neuro-paralysis. The digestive onset may raise diagnostic issues. The objective of our study was to analyze the clinical and epidemiological data of patients diagnosed with botulism and hospitalized in "Gavril Curteanu" Municipal Clinical Hospital (Oradea, Romania). Detection of the Clostridium botulinum neurotoxin (type B) in the laboratories of the National Institute of Medical-Military Research Development "Cantacuzino", Bucharest, Romania (using the mouse bioassays method) confirmed the diagnostics. The statistical analysis was performed using the IBM SPSS software. Forty-eight patients with the diagnosis of foodborne botulism were hospitalized between 2012 and 2018 (36.92% of the total number of cases of botulism reported in Romania). The winter-spring period was the period when most cases were registered (36 patients, p=0.020). Women from rural areas were predominant (but not statistically significant), and the patients' mean age was 39.93±12.59 years. The most common source/cause of botulism was the consumption of homemade ham. The incubation period was 26.68±22.94 h, and 2.25±1.68 days passed from the clinical onset to diagnosis. The results prove that botulism is still a public health issue, especially in areas where homemade products are prepared using inappropriate/unsafe recipes/procedures.

Outbreak of foodborne botulism in Alexandria, Egypt: modulating indications for administration of heptavalent botulinum antitoxin

In October 2019, ninety-four patients were admitted into Alexandria Poison Center (APC) with a history of ingestion of Feseekh (salted fish). In an attempt to allocate the resources, not all patients were given HBAT (botulism antitoxin heptavalent (A, B, C, D, E, F, G) equine immediately. The current study aimed to portray the clinical characteristics of the cases, explore the possible relation between these characteristics and necessity of HBAT administration, explore the reliability of mouse lethal test, and establish a clinical guide for management including preservation of resources. The current prospective study included 94 patients who were admitted to Alexandria Poison Center (APC) in the period from the 29^th of September to the 27^th of October 2019. The patients' data were recorded using a checklist that includes: personal data, past medical history, clinical assessment, investigations, treatment, and the outcome. The checklist was carried out to assess and follow up each patient. Hospitalized patients were categorized according to symptoms consistent with botulism. The equine HBAT, made by Emergent BioSolutions Canada Inc. (formerly Cangene Corporation), was used in the treatment. HBAT was given to thirty-four patients (36.2%) only out of the total admission. However, eighty-two (87.2%) of patients were completely cured, whereas ten patients (10.6%) were discharged with mild neurological sequels and death occurred only in two cases (2.2%). Sixty cases (63.8%) with suspected foodborne botulism could be managed by supportive treatment only with no need for HBAT, while patients with evident neurological signs received HBAT immediately.

Current Developments in Diagnostic Assays for Laboratory Confirmation and Investigation of Botulism

Detection of botulinum neurotoxin or isolation of the toxin producing organism is required for the laboratory confirmation of botulism in clinical specimens. In an effort to reduce animal testing required by the gold standard method of botulinum neurotoxin detection, the mouse bioassay, many technologies have been developed to detect and characterize the causative agent of botulism. Recent advancements in these technologies have led to improvements in technical performance of diagnostic assays; however, many emerging assays have not been validated for the detection of all serotypes in complex clinical and environmental matrices. Improvements to culture protocols, endopeptidase-based assays, and a variety of immunological and molecular methods have provided laboratories with a variety of testing options to evaluate and incorporate into their testing algorithms. While significant advances have been made to improve these assays, additional work is necessary to evaluate these methods in various clinical matrices and to establish standardized criteria for data analysis and interpretation.

Early diagnosis and critical management of wound botulism in the emergency department: a single center experience and literature review

BACKGROUND

Clostridium botulinum remains a major threat to a select population of subcutaneous and intramuscular drug users. We conducted a retrospective study of patients who were diagnosed with wound botulism and their clinical presentations to the Emergency Department (ED).

RESULTS

A total of 21 patients met the inclusion criteria and all had a confirmed history of heroin use disorder. Initial presentation to the ED included generalized weakness (n = 20, 95%), difficulty swallowing (n = 15, 71%), and speech/voice problems (n = 14, 79%). Sixteen patients (76%) also presented with visible skin wounds and fifteen (71%) required mechanical ventilation (MV). Patients who presented with dysphagia as well as dysarthria and/or dysphonia were more likely to require a percutaneous endoscopic gastrostomy (PEG) tube. Patients who required MV and PEG tubes were noted to have a longer hospital length of stay (LOS) due to the severity of the disease progression.

CONCLUSIONS

Emergency physicians should remain vigilant about early recognition of wound botulism, especially in patients who inject drugs.

Clostridium botulinum - like organism bacteremia in a user of black tar heroin

Wound botulism due to introduction of the anaerobic bacteria, Clostridium botulinum, into otherwise sterile, relatively anaerobic tissue is a known complication of black tar heroin use. The treatment of wound botulism requires prompt initiation of antitoxin as well as antimicrobial therapy. We report the case of a patient with polymicrobial bacteremia that included a Clostridium botulinum-like organism who underwent successful treatment of their anaerobic infection with antibiotics and surgical debridement.

Mortality of Western Gulls (Larus occidentalis) Associated with Botulism Type a in Coastal Southern California, USA

A mortality event involving at least 14 Western Gulls (Larus occidentalis) was observed on 10 October 2019 on Huntington State Beach, Orange County, California, US. Clinical signs of affected gulls included generalized weakness and difficulty standing and flying. Six additional Western Gulls with similar clinical signs were admitted for rehabilitation between 24 October and 7 November, including birds from Newport Beach and Laguna Beach, south of Huntington Beach. Eleven carcasses were submitted for postmortem examination, including nine gulls collected on 10 October from Huntington Beach, one collected on 24 October from Laguna Beach, and one collected on 6 November from Newport Beach. Six of seven gulls tested were positive for Clostridium botulinum toxin type A by mouse bioassay, including five collected on 10 October from Huntington Beach and one from Laguna Beach, approximately 23 km south, on 24 October, suggesting the toxin was available to scavenging birds for nearly 2 wk following the original exposure. Botulism type C, and less commonly type E, are most frequently documented in wild birds, including waterfowl and fish-eating birds, respectively. In contrast, botulism type A is the most common cause of foodborne botulism in humans, acquired from food contaminated with C. botulinum spores, but it has not previously been associated with mortality in free-ranging wild birds.

Confirmation of botulism diagnosis in Australian bird samples by ELISA and RT rtPCR

We developed a sandwich ELISA that detects Clostridium botulinum C and D toxins and reverse-transcription real-time PCRs (RT-rtPCRs) that detect botulinum C and D toxin genes, respectively, to replace the mouse bioassay. The toxin genes were closely associated with the toxin molecules and used as surrogates for the presence of toxin. Samples (638) from 103 clinical cases of birds (302) with suspected botulinum toxicity came from wild birds and poultry (9 cases). Samples tested included blood serum, other body fluids, various tissues, gut contents, maggots, water, and sediment. Botulism was diagnosed in 34 cases (all of which had positive samples in the ELISA, the C toxin gene RT-rtPCR, or both assays). Botulism was suspected in 16 cases (each of which had 1 positive sample either in the ELISA or the C toxin gene RT-rtPCR). In the remaining 53 cases, no samples were positive, but botulism could not be excluded in 32 of these cases, whereas there was no indication of botulism or another diagnosis in 21 cases. The D toxin gene was not detected in any of the clinical samples. No C or D toxin genes were detected in 71 pooled cloacal swabs from 213 healthy migratory birds. The use of an ELISA that detects botulinum C and D toxins in combination with a RT-rtPCR for the botulinum C toxin gene can help confirm the diagnosis of botulism in birds.

Rapid Detection of Clostridium botulinum in Food Using Loop-Mediated Isothermal Amplification (LAMP)

Botulinum neurotoxins are considered as one of the most potent toxins and are produced by Clostridium botulinum. It is crucial to have a rapid and sensitive method to detect the bacterium Clostridium botulinum in food. In this study, a rapid detection assay of C. botulinum in food using loop-mediated isothermal amplification (LAMP) technology was developed. The optimal primers were identified among three sets of primers designed specifically based on the partial ntnh gene encoding nontoxic-nonhaemagglutinin (NTNH) for rapid detection of the target DNA in plasmids. The optimal temperature and reaction time of the LAMP assay were determined to be 64 °C and 60 min, respectively. The chemical kit could be assembled based on these optimized reaction conditions for quick, initial high-throughput screening of C. botulinum in food samples. The established LAMP assay showed high specificity and sensitivity in detecting the target DNA with a limit of 0.0001 pg/ul (i.e., ten times more sensitive than that of the PCR method) and an accuracy rate of 100%. This study demonstrated a potentially rapid, cost-effective, and easy-operating method to detect C. botulinum in food and clinical samples based on LAMP technology.

Differentiation, Quantification and Identification of Abrin and Abrus precatorius Agglutinin

Abrin, the toxic lectin from the rosary pea plant Abrus precatorius, has gained considerable interest in the recent past due to its potential malevolent use. However, reliable and easy-to-use assays for the detection and discrimination of abrin from related plant proteins such as Abrus precatorius agglutinin or the homologous toxin ricin from Ricinus communis are sparse. To address this gap, a panel of highly specific monoclonal antibodies was generated against abrin and the related Abrus precatorius agglutinin. These antibodies were used to establish two sandwich ELISAs to preferentially detect abrin or A. precatorius agglutinin (limit of detection 22 pg/mL for abrin; 35 pg/mL for A. precatorius agglutinin). Furthermore, an abrin-specific lateral flow assay was developed for rapid on-site detection (limit of detection ~1 ng/mL abrin). Assays were validated for complex food, environmental and clinical matrices illustrating broad applicability in different threat scenarios. Additionally, the antibodies turned out to be suitable for immuno-enrichment strategies in combination with mass spectrometry-based approaches for unambiguous identification. Finally, we were able to demonstrate for the first time how the developed assays can be applied to detect, identify and quantify abrin from a clinical sample derived from an attempted suicide case involving A. precatorius.

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.

Safety and Clinical Outcomes of an Equine-derived Heptavalent Botulinum Antitoxin Treatment for Confirmed or Suspected Botulism in the United States

BACKGROUND

Botulism is a rare, life-threatening paralytic illness. Botulism Antitoxin Heptavalent (A,B,C,D,E,F,G)-(Equine) (BAT) manufactured by Emergent BioSolutions Canada Inc is an equine-derived heptavalent botulinum antitoxin product indicated for the treatment of symptomatic botulism following documented or suspected exposure to botulinum neurotoxin serotypes A-G in adults and pediatric patients. BAT product was US-licensed in 2013.

METHODS

In the United States, from October 2014 through July 2017, safety and clinical outcomes data were collected under a registry for patients treated with BAT product.

RESULTS

Registry patients had a median age of 51 years (range, 32 days to 92 years). Among 162 patients, 7 (4.3%) experienced BAT product-related serious adverse events, including 1 (0.6%) report each of pneumonia, pneumonia aspiration, ventricular tachycardia, upper gastrointestinal hemorrhage, anaphylactic reaction, acute kidney injury, and acute myocardial infarction. Thirty-one (19.1%) patients had 41 BAT product-related adverse events. Six (3.7%) deaths were reported in the registry. All deaths were attributed to the underlying illness and were assessed as unlikely related to BAT product. Among 113 (69.8%) patients with a final diagnosis of botulism, those treated early (≤2 days) spent fewer days in the hospital (5 vs 15.5 days), in the intensive care unit (ICU) (4 vs 12 days), and on mechanical ventilation (6 vs 14.5 days) than those treated late (>2 days), respectively.

CONCLUSIONS

BAT product was well tolerated in patients. Treatment with BAT product at ≤2 days of symptom onset was associated with shorter hospital and ICU stays, and shorter duration and need for mechanical ventilation, showing clinical benefit associated with early treatment.