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.     

An Outbreak of Botulinum Types A,B, and E Associated With Vacuum-Packaged Salted Fish and Ham

BackgroundBotulinum toxin is a neurotoxin generated during the growth of Clostridium botulinum and can lead to a rare but life-threatening disease with neurologic symptoms. Relatively little is known about the many types of botulinum toxins in China. The clinical symptoms of the different types of botulism toxin–induced illnesses appear after an incubation period and vary greatly by the serotype and degree of exposure to the toxin.Case ReportWe describe 4 patients who consumed vacuum-packaged salted fish and ham and then presented with severe gastrointestinal symptoms, resulting in vomiting and one death. Blood serum and urine samples tested by the botulinum neurotoxin Endopep-MS assay were positive for botulinum toxin types A, B, and E. The patient who consumed the largest amount of fish and ham died after 36 h, and the other patients were treated with botulism antitoxin after being diagnosed with a botulinum toxin–induced illness and recovered after 1 month. These cases illustrate the importance of early diagnosis and early treatment of botulism type E, in particular, because of the risk of respiratory failure and treatment delays, which can result in increased mortality and poorer overall outcomes.Why Should an Emergency Physician Be Aware of This?Our cases illustrate the importance of early diagnosis and especially the treatment of illnesses related to botulism type E because of the risk of respiratory failure and because treatment delays can result in increased mortality and worsened overall outcomes.     

Bioterrorism: class A agents and their potential presentations in immunocompromised patients

A bioterrorism attack would be particularly challenging for medical professionals caring for patients with cancer who often have weakened immune systems. Knowledge of the class A agents and the potential variable presentations in immunocompromised patients is key to early recognition of an outbreak and prompt reporting. The purpose of this article is to present the class A agents: Bacillus anthracis (anthrax), botulinum toxin (botulism), variola virus (smallpox), Yersinia pestis (pneumonic plague), and Francisella tularensis (tularemia). The variable signs and symptoms that may be present in immunocompromised patients with cancer will be discussed with a focus on assessment and early recognition of an outbreak. The availability of vaccines and the implications for patients with cancer receiving these vaccines also will be discussed.     

Botulisme: pas toujours une intoxication par ingestion

Botulism is a rare but paralyzing disease caused by a neurotoxin produced by the anaerobic, spore-forming Gram-positive bacterium. Clostridium botulinum. Temperatures of over 120° C are required to kill the spores, while a one-minute exposure to 85° C is sufficient to inactivate the toxin. Although in most cases botulism is caused by eating contaminated food, experimental data and documented cases of botulism in laboratory workers clearly indicate that an aerosolized form of the toxin may also provoke botulism, i.e., that the bacterium can be inhaled. Moreover, according to experts, the use of aerosolized botullinum toxin could be one of the most frightening weapons in the context of biological warfare. We report one case of documented botulism probably secondary to the inhalation of serotype B toxin from contaminated food. This observation emphasizes that although the clinical diagnosis of botulism is fairly straighforward as it is based on highly indicative symptoms (multiple paralysis of the cranial nerves and atropinic signs), the route of acquisition is not always easy to determine.     

肉毒杆菌食物中毒急诊救治一例

肉毒杆菌食物中毒是由肉毒杆菌释放的肉毒毒素引起严重的神经肌肉中毒症状。该病初期常因临床表现为急性胃肠道中毒症状引起误诊而耽误治疗,严重者导致患者死亡。及早明确诊断和临床对症治疗是成功救治该病的关键。该文总结分析1例肉毒杆菌食物中毒患者的急诊救治过程。经过详细询问该患者的发病史和进食史,进行全面的体格检查、常规检验、影像辅助检查和实验室血浆肉毒毒素检测分析并结合临床症状,该患者确诊为肉毒毒素中毒。在未明确肉毒毒素亚型情况下,对患者大剂量注射A、B型抗肉毒毒素,辅助抗感染和营养恢复神经功能的综合治疗取得较好的治疗效果。患者发病第7日症状好转,救治26 d后康复出院。     

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.     

Infantile Botulism: A Case Report and Review

Background

Infantile botulism is the result of ingestion of Clostridium botulinum spores, and is the most common form of infection with botulism in the United States. Ninety percent of cases occur in infants <6 months old. The infants typically present with vague symptoms such as hypotonia and poor feeding. This article reports an infant with confirmed infantile botulism that presented to the Emergency Department (ED) with complaints of decreased feeding and absence of bowel movements for >1 week.

Objectives

Review a case of infantile botulism, its diagnosis, and treatment.

Case Report

A 4-month-old healthy Caucasian male presented to the ED with a 6-day history of decreased feeding after referral from the pediatrician. He had not had a bowel movement for 9 days, and his parents were also concerned about increasing weakness, as he was no longer able to hold his head up on his own. In the ED, he was minimally interactive. His vital signs were within normal limits, and he had hypoactive bowel sounds and decreased tone throughout. He was admitted to the Children's Hospital and eventually transferred to the Pediatric Intensive Care Unit requiring intubation and mechanical ventilation. The botulism immunoglobulin was administered, and a diagnosis was confirmed with positive botulinum toxin in the stool samples. Full recovery was made by the infant.

Conclusion

Awareness of the symptoms of botulism and a high degree of clinical suspicion is needed to make a prompt diagnosis.     

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.     

Type E botulism

There are seven known serotypes of botulism, designated A through G; almost all human cases of botulism are caused by types A, B, and E. Botulism type E is the predominant serotype causing disease associated with native Arctic foods. In the circumpolar regions of the world, the coastal soils are rich in botulism type E, and consumption of fish and marine animals in these areas are the sources of clusters of botulism. Unlike spores of type A and B, botulism type E can withstand freezing down to 3.5°C. Alaskan native fermentation of fish heads, fish eggs, and beaver tail allow proper anaerobic conditions for botulinum toxin to be elaborated from Clostridium botulinum. The consumption of whale meat, “muktuk” has also been associated with outbreaks of botulism in Alaska and the Canadian Arctic. Elsewhere in the Arctic regions, type E botulism has been associated with Norwegian “rakfisk” prepared by a process similar to fermented Alaskan foods. Outbreaks in Egypt with the salted gray mullet “faseikh”, in Israel and New York linked to salted uneviscerated whitefish “kapchunka”, in Iran from eating “ashbal” an uncooked salmon, and in Japan with “izushi” a traditional fermented fish preserved in rice have occurred. Importation of vacuum-packed whitefish from Alaska and Canada has also been associated with sporadic cases of botulism type E in Europe. In March 2010, the Center for Disease Control and Prevention released the heptavalent antitoxin (H-BAT) for use in the USA, under an Investigational New Drug program, as the preferred treatment for food-borne botulism, including type E, which had not been covered by the bivalent antitoxin, the prior approved antitoxin product in the USA.     

Infant botulism

Although the worldwide incidence of infant botulism is rare, the majority of cases are diagnosed in the United States. An infant can acquire botulism by ingesting Clostridium botulinum spores, which are found in soil or honey products. The spores germinate into bacteria that colonize the bowel and synthesize toxin. As the toxin is absorbed, it irreversibly binds to acetylcholine receptors on motor nerve terminals at neuromuscular junctions. The infant with botulism becomes progressively weak, hypotonic and hyporeflexic, showing bulbar and spinal nerve abnormalities. Presenting symptoms include constipation, lethargy, a weak cry, poor feeding and dehydration. A high index of suspicion is important for the diagnosis and prompt treatment of infant botulism, because this disease can quickly progress to respiratory failure. Diagnosis is confirmed by isolating the organism or toxin in the stool and finding a classic electromyogram pattern. Treatment consists of nutritional and respiratory support until new motor endplates are regenerated, which results in spontaneous recovery. Neurologic sequelae are seldom seen. Some children require outpatient tube feeding and may have persistent hypotonia.     

Type E botulism

There are seven known serotypes of botulism, designated A through G; almost all human cases of botulism are caused by types A, B, and E. Botulism type E is the predominant serotype causing disease associated with native Arctic foods. In the circumpolar regions of the world, the coastal soils are rich in botulism type E, and consumption of fish and marine animals in these areas are the sources of clusters of botulism. Unlike spores of type A and B, botulism type E can withstand freezing down to 3.5°C. Alaskan native fermentation of fish heads, fish eggs, and beaver tail allow proper anaerobic conditions for botulinum toxin to be elaborated from Clostridium botulinum. The consumption of whale meat, "muktuk" has also been associated with outbreaks of botulism in Alaska and the Canadian Arctic. Elsewhere in the Arctic regions, type E botulism has been associated with Norwegian "rakfisk" prepared by a process similar to fermented Alaskan foods. Outbreaks in Egypt with the salted gray mullet "faseikh", in Israel and New York linked to salted uneviscerated whitefish "kapchunka", in Iran from eating "ashbal" an uncooked salmon, and in Japan with "izushi" a traditional fermented fish preserved in rice have occurred. Importation of vacuum-packed whitefish from Alaska and Canada has also been associated with sporadic cases of botulism type E in Europe. In March 2010, the Center for Disease Control and Prevention released the heptavalent antitoxin (H-BAT) for use in the USA, under an Investigational New Drug program, as the preferred treatment for food-borne botulism, including type E, which had not been covered by the bivalent antitoxin, the prior approved antitoxin product in the USA.     

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.     

Bioterrorism's invisible threats: heightened awareness will help nurses identify real and suspected bioterrorism

Ready your nursing staff for potential bioterrorism with this review of the symptoms and treatment of anthrax, smallpox, plague, tularemia, and botulism.     

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.     

Botulism,where are we now?

Introduction.?Botulism is a neuroparalytic illness caused by botulinum toxin, a product of the Clostridium botulinum bacteria and characteristically presents as an acute, symmetrical, descending flaccid paralysis. Albeit it is the most poisonous substance known, which even poses a major threat as biological weapons, purified and highly diluted botulinum toxin can be used to treat a wide variety of conditions associated with muscular hyperactivity, glandular hypersecretions and pain. There are six clinical presentations associated with current occurring botulism, each results from absorption of botulinum toxin into the bloodstream. Aim.?The aim of this review is to summarize the current knowledge on the microbiology, epidemiology, vaccine research and clinical management of human botulism. Conclusions.?Early diagnosis and management rely on history and physical examination. Delay in treatment may allow progression of paralysis, protracted hospitalization and deaths of long-term mechanical ventilation and intensive care unit care. The clinicians must take this disease into consideration of a possible outbreak. Awaiting laboratory confirmation is an egregious error, while awareness of the clinical sign and symptoms of botulism is critical for early diagnosis. Rapid management and followed public health surveillance may greatly alleviate disease severity and decrease mortality rates.     

Wound Botulism Associated with Black Tar Heroin

The incidence of wound botulism is increasing and the epidemiology of the disease is changing. The majority of new cases are associated with injection drug use, in particular, the use of Mexican black tar heroin. This case report and discussion of wound botulism illustrate the following important points: Dysphagia, dysphonia, diplopia, and descending paralysis, in association with injection drug use, should alert the treating physician to the possibility of wound botulism. In such patients, the onset of respiratory failure may be sudden and without clinically obvious signs of respiratory weakness. For the reported patient, maximum inspiratory force measurements were the only reliable indicator of respiratory muscle weakness. This is a measurement not routinely performed in the ED, but may prove essential for patients with suspected wound botulism. To minimize the effect of the botulinum toxin and to decrease length of hospital stay, antitoxin administration and surgical wound debridement should be performed early.     

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.     

Botulism Questionnaire: A tactical tool for community use in a mass casualty incident

A botulism-induced mass casualty incident has the potential to severely compromise a community's health-care infrastructure, based upon its lethality, rare occurrence, and duration of symptoms, which require extensive support and care. Although early recognition and treatment with antitoxin or botulism immunoglobulin are essential to the effective management of this type of an incident, the two major challenges in recognition and treatment are the hundreds, if not thousands, of casualties or potential casualties requiring rapid screening and the fact that most clinicians remain ignorant of the management of botulism. The purpose of this article is to present the Botulism Questionnaire, which will assist with the screening of casualties, provide educational and diagnostic cues for clinicians and the lay public, and create a layer of protection for the health-care infrastructure. The applications of this questionnaire in various formats, the numerous points of distribution, and the variety of platforms from which it can be launched will be explored.     

一例婴儿B型肉毒中毒的实验室诊断

目的对2019年2月来自北京儿童医院1例疑似肉毒中毒的婴儿粪便样品进行实验室诊断，判定是否为肉毒毒素中毒。方法按照GB 4789.12 — 2016稀释处理样品，利用动物实验鉴定肉毒毒素、接种增菌培养基观察变化、采用卵黄培养基进行分离纯化，扩增测序16S rRNA基因并进行序列比对，采用荧光定量PCR方法进行毒素基因分型。结果粪便样本稀释后对小鼠进行腹腔注射，小鼠出现呼吸急促、腹式呼吸，并在4～6 h内死亡，呈现肉毒中毒典型症状。 在卵黄培养基平板上分离到典型肉毒梭菌，镜检观察到芽孢形态，测得的16S rRNA基因序列与GenBank中公开的肉毒梭菌16S rRNA基因序列进行比对，相似率>99%，荧光定量PCR检测显示B型毒素基因阳性，判定该婴儿为B型肉毒中毒。结论此次实验按照国家标准和本实验室建立的荧光定量PCR方法进行鉴定，检测结果和诊断方案为我国婴儿B型肉毒中毒诊断提供参考，也为分析肉毒中毒地域性提供证据，为临床鉴定婴儿B型肉毒中毒提供参考案例。     

Serum positive botulism with neuropathic features

A 32-year-old man presented with multiple cranial neuropathies and his serum was positive for botulism type B. However, serial electrodiagnostic studies were consistent with a primarily neuropathic process, such as Fisher syndrome, rather than a neuromuscular junction disorder. Electrodiagnostic study findings in patients with presumed neuromuscular junction disorders may mimic findings suggestive of a neuropathic process, or the bioassay for botulism may be falsely positive in patients with Fisher Syndrome.