Updated: 6/12/2019

Botulism (Adult)

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Topic
Snapshot
  • A 30-year-old woman presents to the emergency room for blurry vision. She reports that she had been watching a movie when she started seeing double and had difficulty swallowing her popcorn. She recently visited a farm, where she bought and consumed numerous pickles, jams, and cheeses. She states that her arms and face also feel weak. On physical exam, she has symmetric facial weakness, with drooping eyelids. She also has bilateral arm weakness, with loss of deep tendon reflexes.
Introduction
  • Classification
    • Clostridium botulinum
      • anaerobic gram + rod
      • produces botulinum exotoxin
    • transmission
      • ingestion of preformed toxins
      • direct wound contamination
      • inhalation (rare)
  • Epidemiology
    • demographics
      • adults
    • risk factors
      • ingestion of old or expired bottles or cans of food or honey
      • wound contamination
      • intravenous drug use
  • Pathogenesis
    • forms spores
      • highly resistant to heat and chemicals
    • forms heat-labile exotoxin
      • irreversibly inhibits acetylcholine release at the neuromuscular junction by cleaving SNARE proteins
      • ingestion of exotoxin causes adult botulism
    • botulinum toxin is absorbed into bloodstream from mucosal surface
    • botox injections are used for
      • focal dystonia
      • achalasia
      • muscle spasms
      • cosmetic appearance
  • Associated conditions
    • foodborne botulism
    • wound botulism
    • inhalation botulism
Presentation
  • Symptoms
    • gastrointestinal upset in foodborne botulism
  • Physical exam
    • cranial nerve palsies
      • blurry vision
      • ptosis
      • facial weakness
      • drooping eyelids
      • 4 D’s
        • Diplopia
        • Dysarthria
        • Dysphagia
        • Dyspnea
    • autonomic nervous system dysfunction
      • dry mouth
      • postural hypotension
    • descending symmetric muscle weakness and flaccid paralysis
    • absent deep tendon reflexes
Studies
  • Labs
    • typically normal
    • toxin may be detected from serum, stool, or wound
      • process takes a few days, so this is only used as confirmatory testing
  • Making the diagnosis
    • most cases are clinically diagnosed
Differential
  • Guillain-Barré syndrome
    • distinguishing factor
      • typically an ascending paralysis
Treatment
  • Management approach
    • immediate treatment with antitoxin
  • Medical
    • equine-derived heptavalent antitoxin 
      • indication
        • patients > 1 years of age
Complications
  • Respiratory paralysis
  • Permanent paralysis

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Questions (2)
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(M2.ID.17.4799) A 41-year-old man presents to the emergency room with sudden onset of blurry vision one hour ago. He states that he was resting at home when he noticed he had difficulty reading. Currently, he is also starting to see double, and is seeing two images on top of each other. Earlier today, he felt ill with nausea, vomiting, and watery diarrhea, which he attributed to food he had eaten at a picnic the day before. When asked which foods he ate, he lists potato salad, a hamburger, deviled eggs, and pickles made by his neighbor. He also heard that his friend who went to the picnic with him has developed similar symptoms and was seen in another hospital earlier. While in the emergency room, the patient’s temperature is 98.4°F (36.9°C), pulse is 75/min, blood pressure is 122/84 mmHg, and respirations are 13/min. Cranial nerve exam is notable for fixed pupillary dilation, and difficulty depressing both eyes. The remainder of his exam is normal. Which of the following is the pathogenesis of this patient’s presentation?

QID: 109269
1

Decreased acetylcholine release

56%

(24/43)

2

Overactivation of adenylate cyclase

26%

(11/43)

3

Release of interferon-gamma

0%

(0/43)

4

Degradation of phospholipids

5%

(2/43)

5

Inhibition of GABA release

14%

(6/43)

M 5 D

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