Botulism: a rare complication of injecting drug use

Botulism is a rare, naturally occurring disease that may also be caused by deliberate or accidental exposure to the toxins of Clostridium botulinum. The three types of naturally occurring disease are food-borne, wound and intestinal colonisation botulism, dependent on the route of ingress of the toxins. Food related botulism remains rare in the UK, but wound botulism is increasing, particularly associated with intravenous drug use. It presents with an afebrile, descending, symmetrical, flaccid paralysis of motor and autonomic but not sensory nerves. Respiratory failure can occur rapidly with little prior ventilatory deterioration. Management includes respiratory support, specific antitoxin and surgical debridement and antibiotics for cases of wound botulism. We report a case of wound botulism and discuss the presenting features that should alert the emergency physician to the diagnosis of wound botulism.     

Shot by a Gun … Missed by a Provider

Background

Botulism is a paralytic disease caused by the neurotoxin produced by Clostridium botulinum. The majority of cases are due to ingestion or injection drug use. Wound botulism from traumatic injury is exceedingly rare, with only one to two cases reported each year in the United States.

Clostridium botulinum: an increasing complication of heroin misuse.

Wound botulism is a rare infectious disease due to neurotoxin release from the anaerobic, spore-forming bacterium Clostridium botulinum that is becoming an ever more frequent complication of parenteral drug abuse in the Western world. Before the year 2000, no such cases had been reported in the UK and Ireland, but since then the number of proven and suspected cases of wound botulism occurring in parenteral drug users has increased markedly. The diagnosis is often difficult, based on a high degree of clinical suspicion and if not considered in the initial differential diagnosis, then considerable delays in treatment may result. This is the case report of a male heroin user who presented three times to an Emergency Department in the UK before a diagnosis of wound botulism was made and treatment commenced. It is important that emergency clinicians are aware of the possibility of wound botulism in parenteral drug users that present with unusual neurological or respiratory symptomatology.     

Descending polyneuropathy in an intravenous drug user.

A 27-year-old male intravenous drug user presented to the Emergency Department of St James's Hospital with a 1-week history of progressive dysphasia, dysphagia and difficulty 'holding his head up' and 'keeping his eyes open'. He also complained of increasing weakness in his upper limbs, as a result of which he kept dropping things. He was on a methadone program but was using both intravenous heroin and cocaine at the time of presentation. Examination of his motor function revealed generalized hypotonia, hyporeflexia and reduced power in both upper limbs. No sensory loss was observed. Co-ordination was intact. The clinical picture of a proximal symmetrical descending weakness and an absence of sensory loss was suggestive of botulism. Clostridium botulinum is a spore-forming, obligate anaerobe. The three forms of human botulism are food-borne, wound and intestinal. A fourth man-made form is produced from aerosolized botulinum toxin and results in inhalational botulism. A little as 1 g of aerosolized botulinum toxin has the potential to kill 1.5 million people. Toxin is detected in serum or stool specimens in only approximately 46% of clinically diagnosed cases. Treatment involves supportive care and early passive immunization with equine antitoxin. Patients should be regularly assessed for loss of gag and cough reflex, control of oropharyngeal secretions, oxygen saturation, vital capacity and inspiratory force. When respiratory function begins to deteriorate, anticipatory intubation is indicated. Early symptom recognition and early treatment with antitoxin are essential in order to prevent mortality, and to prevent additional cases, it is important to ascertain the presence of similar symptoms in contacts of the patient and local public health officials must be notified as one case may herald an outbreak. Given the continued threat of bioterrorism, the Centre for Disease Control Surveillance System in the United States must also be notified of any cases of botulism.     

Wound botulism associated with black tar heroin and lower extremity cellulitis

Wound botulism is a rare and potentially fatal disease. The use of black tar heroin has spawned an increase in the incidence of the disease, with the majority of cases occurring in California. The use of botulism antitoxin and surgical debridement are recommended to decrease hospital stay. For this to be effective, the diagnosis of wound botulism first must be considered, followed by an aggressive search for any area of infection that may be debrided. This case report demonstrates several factors to consider in patients presenting with symptoms of botulism poisoning: occurrence away from the Mexico border, no obvious abscess, and the need for prolonged ventilatory support. This case report documents a prolonged hospital stay, possibly caused by delay in administration of antitoxin in a patient with cellulitis that was not considered appropriate for debridement.     

111株铜绿假单胞菌感染的分布及药敏分析

目的了解铜绿假单胞菌对抗菌药物敏感及耐药情况，从而指导临床合理用药。方法对南宁市第七人民医院各种临床标本中所分离的铜绿假单胞菌药敏结果进行回顾性分析。结果共分离铜绿假单胞菌111株，其中呼吸道（痰及咽拭子）分离出80株（72．0％）；伤口分泌物（脓及分泌物）分离出25株（22．5％）。铜绿假单胞菌对亚胺培南、美罗培南、头孢哌酮／舒巴坦、阿米卡星的耐药率分别为6．3％、9．9％、10．8％、18．0％；对复方新诺明、氨苄西林的耐药率高达97．3％及91．9％。结论铜绿假单胞菌主要以呼吸道及伤口感染为主，其对抗菌药物耐药情况严重。严格执行抗菌药物的管理制度，使临床用药在药敏试验结果指导下进行，对控制铜绿假单胞菌耐药率具有重要意义。碳青霉烯类抗菌药物（亚胺培南、美罗培南）可作为南宁市第七人民医院铜绿假单胞菌重症感染的首选药物；头孢哌酮／舒巴坦、阿米卡星可作为次选药物。     

Botulin toxin: a weapon in terrorism.

Clostridium botulinum, the causative agent of botulism is an anaerobic, spore forming gram-positive bacillus. C. botulinum causes three types of botulism; foodborne botulism, wound botulism, and infant botulism. Most strains of the bacterium produce a potent, muscle-paralyzing neurotoxin. Respiratory failure secondary to paralysis of the respiratory muscles can lead to death unless appropriate therapy is promptly initiated. Due to the severity and potency of this neurotoxin, its importance as a biological weapon is of major concern to public health officials.     

Patient-ventilator interaction during acute lung injury, and the role of spontaneous breathing: part 1: respiratory muscle function during critical illness

Since the early 1970s there has been an ongoing debate regarding the wisdom of promoting unassisted spontaneous breathing throughout the course of critical illness in patients with severe respiratory failure. The basis of this debate has focused on the clinical relevance of opposite problems. Historically, the term "disuse atrophy" has described a situation wherein sustained inactivity of the respiratory muscles (ie, passive ventilation) results in deconditioning and weakness. More recently it has been referred to as "ventilator-induced diaphragmatic dysfunction." In contrast, "use atrophy" describes a situation where chronic high-tension inspiratory work causes structural damage to the diaphragm and weakness. Both laboratory and clinical studies demonstrated that relatively brief periods of complete respiratory muscle inactivity, as well as intense muscle loading, result in acute inflammation, loss of muscle mass, and weakness. Yet in critical illness other factors also affect respiratory muscle function, including prolonged use of neuromuscular blocking agents, administration of corticosteroids, and sepsis. This makes the attribution of acquired respiratory muscle weakness and ventilator-dependence to either ventilator-induced diaphragmatic dysfunction or loaded breathing extremely difficult. Regardless, the clinical implications of this research strongly suggest that passive mechanical ventilation should be avoided whenever possible. However, promotion of unassisted spontaneous breathing in the acute phase of critical illness also may carry a substantial risk of respiratory muscle injury and weakness. Use of mechanical ventilation modes in a manner that induces spontaneous breathing effort, while simultaneously reducing the work load on the respiratory muscles, is probably sufficient to minimize both problems.     

粤北地区铜绿假单胞菌的临床分布和耐药性特点

目的分析粤北地区临床分离的铜绿假单胞菌株分布特点和对常用抗菌药物的耐药特点,为临床合理选用抗菌药物治疗、预防感染及防止耐药菌株的产生提供参考依据。方法按常规方法从粤北地区临床标本中分离培养铜绿假单胞菌,应用WHONET5.6和SPSS19.0统计软件分析2013-2014年的药敏试验数据,分析铜绿假单胞菌的耐药特点。结果 584株铜绿假单胞菌感染主要来自于重症医学科、骨科和呼吸内科,以呼吸道标本和伤口分泌物标本为主;铜绿假单胞菌对药敏试验的12种抗菌药物具有不同程度的耐药性,其中耐药率最高的是庆大霉素,对喹诺酮类、碳青霉烯类、加酶抑制剂类耐药率相对较低,头孢吡肟、环丙沙星、左氧氟沙星和头孢哌酮/舒巴坦的耐药性呈下降趋势。结论铜绿假单胞菌主要引起肺部和伤口感染,尤其在重症医学科、骨科和呼吸内科的老年患者多见;该菌对临床常用抗菌药物的耐药率相对较低,但临床仍需规范使用抗菌药物,以减少耐药菌株、尤其是多重耐药株和泛耐药株的产生。     

Management of botulism

OBJECTIVE: To provide a concise review of the presentation and treatment of botulism. DATA SOURCES: Searches of MEDLINE (1966-November 2001), tertiary references, and public and government Internet sites were conducted. STUDY SELECTION: All articles and additional references from those articles were thoroughly evaluated. DATA SYNTHESIS: Clostridium botulinum toxin blocks acetylcholine release in a dose-dependent fashion, resulting in acute symmetric diplopia, dysarthria, dysphonia, dysphagia, and possible neurologic sequelae despite the route of exposure (i.e., food-borne, wound, intestinal, inhalation). Disease secondary to genetically engineered C. botulinum may differ from that of inadvertent exposure. Present treatment is primarily supportive care, respiratory support, rapid decontamination, and antitoxin administration (i.e., trivalent, pentavalent, heptavalent antitoxin). Early initiation of antitoxin limits the extent of paralysis, but does not reverse it. CONCLUSIONS: Supportive care and the use of antitoxin have been effective in the treatment of botulism from food-borne, intestinal, and wound exposure. However, the effectiveness of antitoxin in the treatment of inhaled C. botulinum has not been proven.     

Infant botulism: case report and clinical update

Infant botulism occurs in infants between 1 week and 11 months of age and results from the in vivo production of neurotoxin by Clostridium botulinum. The clinical spectrum ranges from asymptomatic carriers, through various degrees of paralysis, to sudden death. The classic clinical presentation is an afebrile child with constipation and generalized weakness manifested by poor head control, poor suck, and weak cry. Symptoms can progress to include cranial nerve palsies, respiratory arrest, and adynamic ileus. Treatment is supportive in an intensive care setting. Antibiotics and antitoxin are not indicated. The morbidity and mortality is less than 3% in hospitalized patients and complete recovery can be expected. The environmental and dietary factors associated with infection are discussed.     

中药注射液致老年患者临床不良反应特点分析

目的探讨中药注射液致老年患者临床不良反应的特点,为临床合理用药提供参考。方法对69例使用中药注射液治疗且出现不良反应的患者用药情况、不良反应发生时间及不良反应临床表现等相关资料进行回顾性分析,归纳不良反应发生的特点,提出合理用药建议。结果老年患者中药注射液不良反应的发生与性别无关,发生不良反应的时间多在用药后24 h以内,用药后发生不良反应患者最多的为清开灵注射剂,其次为双黄连注射剂,发生不良反应患者最少的为痰热清注射剂和丹参注射剂。不良反应多表现在患者的皮肤、附件及注射部位,对消化系统、循环系统、呼吸系统及运动系统也存在一定的影响。结论老年患者中药注射液不良反应发生率较高,临床使用中药注射液时应加强风险防范意识,充分考虑老年人的生理特点,根据辩证论治的基本思路合理选择药物。     

Pneumothorax associated with mechanical insufflation-exsufflation and related factors

Impaired cough that results in ineffective airway secretion clearance is an important contributor to pulmonary complications in patients with neuromuscular weakness including spinal cord injury. Mechanical insufflation-exsufflation (MI-E) is a respiratory aid used by patients with weak respiratory muscles to increase cough peak flows and improve cough effectiveness. Relative contraindications to MI-E are said to include susceptibility to pneumothorax, but the association of pneumothorax with MI-E use has never before been described. We report two cases of pneumothorax in patients with respiratory muscle weakness associated with daily use of MI-E: one was a 58-yr-old male with C4 ASIA C tetraplegia, and the other was a 26-yr-old male with Duchenne muscular dystrophy. Both patients also used positive-pressure ventilatory assistance. Although seemingly rare in this patient population, ventilator users also using MI-E who have increasing dyspnea or who require increasing positive inspiratory pressures when using noninvasive ventilation should be evaluated for pneumothorax.     

Susceptibility of Clostridium botulinum to thirteen antimicrobial agents.

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

Care of the chronic tracheostomy

A minority of patients with neuromuscular disease require placement of a tracheostomy, usually for the purpose of providing mechanical ventilation. Often the tracheostomy is performed during a hospital admission for an acute illness. The debate about the appropriate timing of tracheostomy in critically ill patients has not been resolved; however, the weight of evidence now favors performing a tracheostomy early (within 7 d of translaryngeal intubation) if the period of mechanical ventilation is likely to be prolonged beyond 3 weeks. For patients with chronic progressive weakness who develop respiratory difficulty, the consensus of opinion is that tracheostomy should be performed in patients with severe bulbar involvement, inability to effectively cough up secretions despite mechanical aids for secretion clearance, or for those who are unable to tolerate or fail noninvasive ventilation. The decision to perform tracheostomy in patients with chronic neuromuscular weakness involves consideration of several factors, including complications, resources, quality of life, ethical issues, cosmetic issues, and cost. Complications from tracheostomy and physician-perceived poor quality of life often lead to a negative bias, such that some patients may be denied this life-saving procedure. Special training is needed to provide long-term tracheostomy care, and an organized approach should be followed to decannulate patients who recover from their acute illness. Appropriate and skilled care could significantly improve the longevity and quality of life of those patients with neuromuscular disease who have a tracheostomy for long-term ventilation.     

New targets in the search for preventive and therapeutic agents for botulism

Botulism is a severe neuroparalytic disease resulting from exposure to one of the most poisonous toxins to humans. Because of this high potency and the use of toxins as biological weapons, botulism is a public health concern and each case represents an emergency. Current therapy involves respiratory supportive care and anti-toxins administration. As a preventive measure, vaccination against toxins represents an effective strategy but is undesirable due the rarity of botulism and the effectiveness of toxins in treating several neuromuscular disorders. This paper summarizes the current issues in botulism treatment and prevention, highlighting the challenge for future researches.     

L'insuffisance respiratoire aiguë du syndrome de Guillain-Barré et de la myasthénie auto-immune. De la détection au sevrage de la ventilation mécanique

Guillain-Barré syndrome (GBS) and myasthenia gravis (MG) are the most common neuromuscular causes of acute respiratory failure. Their prognosis has been considerably improved by the advent of mechanical ventilation. However patients remain at risk of respiratory arrest, because the severity of respiratory failure is often underestimated as patients often have minimal symptoms. Aspiration pneumonia, nonspecific complications of mechanical ventilation and weaning failure may also occur. Respiratory failure may be due to weakness of inspiratory and/or expiratory muscles, which can be assessed by the measurement of vital capacity (VC) and static maximal pressures. Bulbar dysfunction may also be a contributory factor. Patients with respiratory symptoms, especially orthopnoea, a reduction of VC below 60% of the predicted value or bulbar weakness must be referred to intensive care, particularly since GBS follows a progressive course and MG is characterized by fluctuating motor deficit. Criteria for mechanical ventilation include signs of respiratory distress, hypoxemia, hypercapnia or a VC below 20% predicted, but because of the risk of aspiration, major bulbar weakness can also be considered to be an indication. Weaning should only be started if there has been neurological improvement and VC is above 20%. Extubation should be preceded by a prolonged trial of spontaneous ventilation. Measurement of VC is essential at each step of the evolution of neuromuscular respiratory failure.     

Emergency department presentation of type A botulism

In October 1983, 28 people became ill with type A botulism in a common-source, food-borne outbreak. Thirteen of these patients presented to an emergency department for initial medical evaluation. The records of these thirteen patients were examined retrospectively in an attempt to characterize the initial presenting symptoms. All patients complained of at least three of four symptoms (generalized weakness, diplopia, dry mouth, and difficulty speaking). Emergency physicians can play a pivotal role in limiting the extent of common-source botulism outbreaks by early recognition of the disease and immediate mobilization of community public health resources.     

Acute and subacute weakness

Respiratory failure is a common complication of acute neuromuscular disease and high cervical cord lesions and should be monitored by measuring forced vital capacity and respiratory rate. Urgent imaging is mandatory if there is any clinical suspicion of spinal cord disease. Treatment of Guillain-Barré syndrome with plasma exchange or intravenous immunoglobulin (IVIg) speeds up the rate of recovery. Treatment of patients in a myasthenic crisis with plasma exchange or IVIg often results in significant short-term improvement. A drug side effect or metabolic disturbance should be considered in a patient presenting acutely with proximal weakness, myalgia and high creatine kinase.     

呼吸内科150例患者抗生素合理使用情况分析

目的分析评价呼吸内科患者抗生素合理使用情况。方法选取某医院150例呼吸内科住院患者为研究对象,通过查看病历等方式,调查分析抗生素的使用情况。结果 150例呼吸内科患者全部采用抗生素治疗,抗生素使用率为100.00%。其中抗生素使用频度最高的是头孢类,其次是大环内酯类。头孢类抗生素中以头孢曲松、头孢哌酮和头孢他定使用频度最高,且头孢曲松和头孢哌酮的药物利用指数(DUI)均超过1,存在不合理使用现象;抗生素联合应用频率略高。结论呼吸内科疾病患者存在抗生素药物使用不完全合理现象,建议临床呼吸内科医生调整患者抗生素的使用,加强合理用药,促进患者健康。