Open Tibial Fracture Complicated by Wound Botulism: A Case Study

Botulism is a neuroparalytic disease most commonly caused by foodborne ingestion of neurotoxin types A, B, and E, and is often fatal if untreated. Clinicians should be able to recognize the classic symptoms of botulinum intoxication (12). Owing to its rarity, there are a limited number of studies evaluating the clinical care of patients with wound botulism (10). We present an infected tibial non-union with botulism who underwent a successful radical excision and bone transport. The patient tolerated the procedure well.     

Wound botulism in drug addicts in the United Kingdom

Clostridium novyi has recently been identified as the causative organism responsible for the deaths of 35 heroin addicts who had injected themselves intramuscularly. We present two heroin addicts who developed C. botulinum infection following intramuscular or subcutaneous injection of heroin. Like C. novyi, this grows under anaerobic conditions and clinical presentation may be similar; however, descending motor or autonomic signs are invariably present in botulism. The prognosis is good if the diagnosis is made early and appropriate treatment commenced.     

Severe adult botulism.

A case of severe adult botulism with paralysis, respiratory failure and cranial nerve palsies is presented. The pathophysiology, clinical manifestations, diagnosis and treatment options for botulism are discussed.     

Botulism with respiratory insufficiency requiring extra corporeal carbon dioxide removal.

Despite a low incidence of botulism in the industrialized world some cases occasionally occur in Germany after eating contaminated food. Because botulism is rarely seen, most physicians are unfamiliar with its early recognition and treatment. However, immediate intensive care treatment is important. We report the case of a previously healthy 54-year-old female who developed signs of botulism after eating vacuum packed smoked fish and developed severe respiratory insufficiency with difficult carbon dioxide elimination in the days following.     

Foodborne botulism, epidemiologic aspects

With a mean of 30 cases reported per year, following Italy, France ranks second in the European countries in terms of incidence of botulism. Food stuff of commercial origin, of artisanal or industrial manufacture fabrication, is increasingly implicated in the genesis of outbreaks of botulism. Moreover, the modern methods of conserving food (vacuum packed food, frozen food...) allow the development of Clostridium bacteria. The diversification of the risks related to the type of products incriminated and to the new conservation methods, associated with the extension of commercial exchanges, result in the risk of widespread internationally outbreaks of botulism.     

Botulism in a pregnant intravenous drug abuser

A case of botulism is reported in a heroin-abusing parturient who initially presented with lethargy and slurred speech. The diagnostic difficulty, complications, intensive care and anaesthetic management of this case are discussed, with particular reference to the pregnancy and the effects of both botulism and its empirical treatment on the fetus. A short review is provided of a condition that has seen a marked increase in its incidence since 2000.     

Airway complications of infant botulism: ten-year experience with 60 cases.

OBJECTIVE: The study goal was to understand the incidence, etiology, and management of airway complications in infant botulism. METHODS: We conducted a retrospective review of the period from January 1, 1987, to December 31, 1997. SETTING: Urban tertiary care children's hospital. RESULTS: Of 60 children with infant botulism, 37 (61.7%) required endotracheal intubation for a mean of 21 days. No patient required a tracheostomy. Airway complications (stridor, subglottic stenosis, granuloma formation) occurred in 5 (13.5%) of 37 patients, with 3 requiring surgical bronchoscopy. Of the 37 children, 14 (37.8%), including 4 with airway complications, had endotracheal tube leak pressures recorded. In 3 (50%) of 6 patients with measured leak pressures of greater than 40 cm H2O, airway complications developed. Complications did not develop in patients with leak pressures of less than 20 cm H2O. No correlation between length of intubation and complications could be established. CONCLUSION: Airway complications in infant botulism may be accompanied by high leak pressures and can be managed with endoscopic techniques. The study data suggest that leak pressures should be measured on a regular basis and maintained at less than 20 to 25 cm H2O. A prospective trial to study this issue is warranted. Tracheotomy is not routinely necessary. A high index of suspicion, early diagnosis, and prompt intervention are required for the optimal management of airway complications in infant botulism.     

Infant botulism mimicking Hirschprung's disease

We report a case of infant botulism presenting as primary colonic ileus—mimicking Hirschprung's megacolon. Infant botulism should be considered in any infant with constipation and neurologic abnormalities.     

Transient paralysis of the bladder due to wound botulism.

In the last 10 years, wound botulism has increasingly been reported and nearly all of these new cases have occurred in injecting-drug abusers. After absorption into the bloodstream, botulinum toxin binds irreversibly to the presynaptic nerve endings, where it inhibits the release of acetylcholine. Diplopia, blurred vision, dysarthria, dysphagia, respiratory failure and paresis of the limbs are common symptoms of this intoxication. Surprisingly and despite the well-known blocking action of the botulinum toxin on the autonomic nerve system, little attention has been paid to changes in the lower urinary tract following acute botulinum toxin poisoning. Here we report a case of bladder paralysis following wound botulism. Early diagnosis and adequate management of bladder paralysis following botulism is mandatory to avoid urologic complications. Accordingly, the prognosis is usually favorable and the bladder recovery complete.     

Botulism

Opinion statement Botulinum toxin is the most potent toxin known to humans and as little as 100 ng can be lethal. The toxin blocks peripheral cholinergic neurotransmission at the neuromuscular junction and cholinergic autonomic nervous system by introducing an endopeptadase enzyme into the presynaptic side of the synapse. The endopeptadase cleaves acetylcholine vesicle docking proteins that are required for the synapse to release acetylcholine into the synaptic cleft. Botulism occurs from consumption or inhalation of preformed botulinum toxin or growth of Clostridium botulinum bacteria in the infant gastrointestinal tract or within a wound. Growth of C. botulinum in the immature gut or wound will release botulinum toxin that reaches the circulation. All forms of botulism cause progressive weakness, bulbar signs (blurred vision, diplopia, mydriasis, dysphagia, and dysarthria), and respiratory failure with normal sensation and mentation. Treatment is aimed at 1) maintaining respiration via intubation and mechanical ventilation, 2) stopping progression of weakness by administration of botulinum antitoxin (equine trivalent botulinum antitoxin for adults and botulism immune-globulin intravenous-human for infant botulism), and 3) preventing complications from weeks of paralysis with good supportive care. The source of the botulinum toxin should be identified to prevent additional cases. Patients can recover normal muscle strength within weeks to months, but usually complain of fatigue for years.     

Botulism toxin,bioterrorist weapon

BOTULISM AND BIOWARFARE: Botulism is a severe neuro-paralysing infection due to a toxin produced by Clostridium botulinum. The use of the botulinum toxin for terrorist aims in the form of aerosols is a perfectly credible eventuality. The botulinum toxin is the most potent toxin known; it is easy to produce and can lead to massive destruction. DEPENDING ON THE CONTAMINATION: The clinical forms of botulism depend on the mode of contamination. Botulism through inhalation can only be the result of a deliberate act using an aerosol. The clinical symptomatology is identical to that of the other forms. PREVENTION: In the case of a bio-terrorist attack with an aerosol of botulinum toxin, the subjects exposed should be vaccinated as a prophylactic measure with trivalent antitoxin vaccine (types A, B and E). This vaccine must be administered as rapidly as possible in symptomatic patients. A single case of botulism acquired by inhalation corresponds to an act of terrorism.     

Botulism, a clinical diagnosis

Foodborne botulism results from the effect of a neurotoxin produced by a sporulated anaerobic bacillus called Clostridium botulinum. The mode of contamination occurs through the consumption of foodstuff, already contaminated by the neurotoxin. Following an incubation period that varies from 2 hours to 8 days, the symptoms start with intestinal problems. Then paralysis of the cranial nerve pairs sets in, classically manifested by diplopia, dysphagia, dysphonia, areactive mydriasis and ptosis. The onset of motor disorders occurs in descending order with possible involvement of the respiratory muscles, hence requiring reanimation measures and sometimes mechanical ventilation. The diagnosis of botulism is clinical. Identification of the botulinum toxin in the blood or faeces of the patients or in the contaminating food stuff confirms the diagnosis.     

Neuromuscular disorders: relevance to anaesthesia and intensive care

Although relatively rare, neuromuscular disease is important to both anaesthetists and intensivists as it may complicate general anaesthesia and result in neurogenic respiratory failure. The most common diseases that will be encountered in a general anaesthetic practice include motor neurone disease, Guillain–Barré syndrome, botulism, myasthenia gravis and the muscular dystrophies. The clinical features and anaesthetic implications for these conditions are discussed.     

Two cases of foodborne botulism with home-preserved asparagus

Botulism is a rare but potentially fatal disease caused by toxins produced by Clostridium botulinum. We report botulism in two adult females, one of them just tasting from "bad" asparagus and the other eating the full portion. Both patients survived after intermittent mechanical ventilation and trivalent antitoxin administration. The diagnosis was confirmed by detection of botulinum toxin. Acute onset of bilateral cranial neuropathies associated with symmetric descending weakness as well as some key features of the botulism syndrome including absence of fever, symmetric neurologic deficits, the patients remaining responsive and no sensory deficits, with the exception of blurred vision, led to the clinical diagnosis in the first presenting case which was then easily made in the second. Despite the fact that amount of toxin ingested, time-to-symptom development, and time-to-recovery markedly differed in the two patients, their maximal disease severity was similar.     

Cardiac arrest due to succinylcholine-induced hyperkalemia in a patient with wound botulism

Cardiac arrest due to hyperkalemia is a known complication of succinylcholine administration in patients with neuromuscular disease, extensive burns, and prolonged immobility. We report a case of hyperkalemic cardiac arrest following the administration of succinylcholine in a patient suffering from wound botulism.     

Neuromuscular disorders: relevance to anaesthesia and intensive care

Neuromuscular diseases are relatively rare, but it is important for both anaesthetists and intensivists to have a working knowledge of the common diseases as they may complicate general anaesthesia and result in neurogenic respiratory failure. The most common neurological condition seen in the intensive care unit is that of critical illness neuropathy; this subject is covered elsewhere in the journal. The diseases most commonly encountered in general anaesthetic practice include motor neurone disease, Guillain-Barré syndrome, botulism, myasthenia gravis and the muscular dystrophies.     

Neuromuscular disorders: relevance to anaesthesia and intensive care

Neuromuscular diseases are relatively rare but it is important for both anaesthetists and intensivists to have a working knowledge of the common diseases, as they may complicate general anaesthesia and result in neurogenic respiratory failure. The most common neurological condition seen in the intensive care unit is that of critical illness neuropathy; this subject is covered elsewhere in the journal. The diseases most commonly encountered in general anaesthetic practice include motor neurone disease, Guillain-Barré syndrome, botulism, myasthenia gravis and the muscular dystrophies.     

Achalasia

This article reviews the diagnosis and treatment of achalasia, a rare esophageal motility disorder characterized by absent peristalsis and failure of the lower esophageal sphincter (LES) to relax. Various treatment options including management with sublingual nitrates or calcium channel blockers, injection of the LES with botulism toxin, pneumatic dilation of the LES, and pneumatic dilation are discussed. Laparoscopic Heller myotomy is minimally invasive with incumbent low morbidity and mortality rates, and combined with a partial fundoplication is a durable, safe, and effective treatment option for patients with achalasia.     

Hypopi of Hypodectes propus (Acari: Hypoderatidae) in two southern crowned pigeons (Goura scheepmakeri)

Necropsy of 2 4-year-old southern crowned pigeons (Goura scheepmakeri) that died from a presumed case of botulism revealed hundreds of small, cyst-like structures in the pectoral subcutaneous tissues. The structures were identified as heteromorphic deutonymphs of Hypodectes propus (Order Astigmata) of the family Hypoderatidae. The immobile, immature hypopi were individually encapsulated, mostly in adipose tissue, and evoked only a mild inflammatory infiltration of predominately macrophages with some heterophilic granulocytes. The infection was not considered a serious health problem and was interpreted as an incidental finding. To our knowledge, this is a new host record for H. propus.     

The basic science of botulinum toxin

Understanding the basic science of botulinum toxin should serve as a fundamental first step for clinical therapy. This article endeavors to cover many aspects of basic research that also have clinical import. The two principal toxins of the clostridial family, Clostridium tetani and C botulinum, are described in detail. The five clinical manifestations of botulism poisoning are also outlined, and structural aspects and the mechanism of action of botulinum toxin are then presented. Finally, the immunologic and pharmacologic principles that define the various serotypes of botulinum toxin are set forth.