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.     

Human Botulism Caused by Clostridium Botulinum Type E: The Birmingham Outbreak

Four elderly patients developed botulism following ingestionof tinned Alaskan salmon contaminated with Clostridium botulinumtype E. Severe skeletal muscle paralysis, occurring within 18hours in peripheral, respiratory and facial, extrinsic ocularand pharyngeal muscles, resulted in progressive respiratoryfailure, ptosis, loss of eye movements, dysphonia and dysphagia.In addition, the development of intestinal ileus, loss of vagalcardiac control, hypotension and lack of vasomotor responseto either postural change, stimulation by cold or the Valsalvamanoeuvre indicated dysfunction of both parasympathetic andsympathetic nervous systems. Sensation was unimpaired and noalteration of consciousness occurred despite the presence ofextensive abnormal delta activity in the EEGs of all patients. The diagnosis of botulism was confirmed by demonstration ofCl. botulinum type E toxin in the serum of all four patientsand in salmon remnants from the suspect tin, in which Cl. botuilnumtype E spores were also identified. Standard supportive intensive care and antitoxin therapy werecomplemented by the use of a novel neuromuscular blockade antagonist,4-aminopyridine. This agent was shown by electromyography tobe effective in restoring neuromuscular transmission and, clinically,to produce almost complete reversal of peripheral paralysis.However, this effect was transient and there was no detectableeffect on respiratory muscle. Administration of 4-aminopyridineby constant infusion produced sustained improvement in peripheralmuscle power, but there was no additional effect on respiratorymuscle, and convulsive phenomena occurred following treatment.Despite these latter problems, 4-aminopyridine produced a greaterresponse in peripheral muscle than might have been expectedwith guanidine and further studies, possibly with less neurotoxicanalogues, are indicated.     

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.     

One collective case of type A foodborne botulism in Corsica

Foodborne botulism is rare in 21st century Western Europe. The purpose of this report is to describe a collective case of type A botulism caused by ingestion of artisanal-produced food (canned green beans and/or salted roast pork). Five of the seven persons who shared the meal presented signs of severe intoxication leading to the fatal respiratory failure in one 18-year-old girl. Three patients required mechanical ventilation for durations ranging from 37 to 78 days and developed severe infectious, respiratory and/or psychiatric complications. In 4 out of the 5 patients, trivalent antitoxin was administered between days 2 and 7 but did not avoid the need for long-term intubation/mechanical ventilation. Treatment with 3,4-diaminopyridine was ineffective in the 26-year-old man who required long-term breathing assistance. This case of collective foodborne botulism illustrates the potential severity of this hazard.     

One collective case of type A foodborne botulism in Corsica

Foodborne botulism is rare in 21st century Western Europe. The purpose of this report is to describe a collective case of type A botulism caused by ingestion of artisanal-produced food (canned green beans and/or salted roast pork). Five of the seven persons who shared the meal presented signs of severe intoxication leading to the fatal respiratory failure in one 18-year-old girl. Three patients required mechanical ventilation for durations ranging from 37 to 78 days and developed severe infectious, respiratory and/or psychiatric complications. In 4 out of the 5 patients, trivalent antitoxin was administered between days 2 and 7 but did not avoid the need for long-term intubation/mechanical ventilation. Treatment with 3,4-diaminopyridine was ineffective in the 26-year-old man who required long-term breathing assistance. This case of collective foodborne botulism illustrates the potential severity of this hazard.     

Prevalence of diabetes mellitus in Alaskan Eskimos, Indians, and Aleuts

The prevalence of diabetes mellitus in Alaska Natives has been thought to be low, but no survey of this condition in all natives has been conducted. Medical records from 1979 to 1985 were reviewed to determine the prevalence of diagnosed diabetes mellitus in Alaska Natives. Computerized outpatient and inpatient medical record data and clinician reports were used to identify cases. As of December 1985, 610 living Alaska Natives fulfilled diagnostic criteria for diabetes. Type II diabetes mellitus was found in 564 subjects, type I diabetes was found in 15 subjects, and unspecified type of diabetes was found in 31 subjects. The overall age-adjusted prevalence of diabetes mellitus, 15.7/1000, was lower than the overall United States rate of 24.7/1000. However, age-adjusted prevalence varied considerably by ethnic group; the prevalence was 27.2/1000 among Aleuts, 22.0/1000 among Alaskan Indians, and 8.8/1000 among Alaskan Eskimos. Rates within the Eskimo subgroups varied by a factor of four. Compared with previous reports, the prevalence of diabetes mellitus in Alaskan Eskimos appears to have increased. Diabetes mellitus is no longer a rare condition among Alaska Natives.     

肉毒抗毒素现状和发展趋势概述

肉毒毒素是已知毒性最强的生物毒素,其引起的肉毒中毒时有发生,甚至会致死.肉毒抗毒素是目前唯一的肉毒中毒特异性治疗手段,尽早使用肉毒抗毒素对提高肉毒中毒的治疗效果具有重要意义.目前国内外批准上市的肉毒抗毒素基本都是马源性制剂,存在引起过敏反应等不良反应的风险.本文对肉毒抗毒素的国内外现状、生产工艺、质量控制和临床应用等现...     

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.     

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.     

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.     

The Popularity of the Biologically-Based Therapies During Coronavirus Pandemic Among the Google Users in the USA,UK, Germany,Italy and France

ObjectThe aim of this retrospective infodemiological study was to evaluate people’s interests in biologically-based (B-B) complementary and alternative medicine (CAM) therapies such as herbs, foods, and supplements during the coronavirus pandemic via analysis of Google search engine statistics.Design & settingsThe category, period, and regions selected in the Google Trends were “health,” “15 January–15 May 2020,” in the United States of America (USA), the United Kingdom (UK), Germany, Italy, and France, respectively. The most commonly searched herbs, foods and supplements (n = 32) during the pandemic were determined from a pool of keywords (n = 1286) based on the terms’ relative search volumes (RSVs) within the last five years. Correlation analyses were conducted to investigate associations between coronavirus-related parameters with each keyword’s RSV for each country. Selected keywords (n = 25) were analyzed using the gtrendsR package in the R programming language; the ggplot2 package was used to visualize the data, the Prophet package was used to estimate the time series, and the dplyr package was used to create the data frame.ResultsSignificantly strong positive correlations were identified between daily RSVs of the terms “black seed,” “vitamin C,” “zinc,” and “quercetin,” and search queries for “coronavirus” and “COVID-19” in the USA (Spearman’s correlation coefficient > 0.8, p < 0.05), and between the RSVs of the terms “vitamin C” and “zinc,” and daily search queries for “coronavirus” and/or “COVID-19” in the UK (Spearman’s correlation coefficient > 0.8, p < 0.05).ConclusionGoogle Trends can be a beneficial tool for following public interest in identifying outbreak-related misinformation, and scientific studies and statements from authorities and the media play a potential role in driving internet searches.     

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.     

Analysis of causal models of diet for patients with head and neck cancer receiving radiation therapy

PurposeThis study seeks to establish causal models of diet which maintain the appetite of head and neck cancer patients receiving radiation therapy.Sample and methodsWe collected data from 208 patients at two radiation doses, 30/50 Gy, using a questionnaire on appetite and analyzed the items using structural equation modeling.ResultsIn the causal model for 30 Gy, we established a path using the four intervening variables “ease of consuming foods in smooth forms,” “ease of consuming foods with a chewable texture and suitable temperature,” “ease of consuming lightly seasoned foods with a flavorful smell,” and “overall ease of consuming a given meal” from the temporal relationship between “dietary preferences” and “maintaining appetite while caring for the oral cavity.” In the causal model for 50 Gy, we established a path between “ease of consuming foods with a mild temperature and smell,” and “maintaining appetite while caring for the oral cavity” using the four intervening variables “ease of consuming foods that are easy to swallow,” “ease of consuming foods that dissolve well in the mouth,” “ease of consuming foods with a mild taste,” and “overall ease of consuming a given meal.” The goodness of fit indices for both models were above 0.85 for both the goodness of fit index (GFI) and adjusted GFI (AGFI), and less than 0.08 for root mean square error of approximation (RMSEA), indicating a satisfactory goodness of fit.ConclusionsFood characteristics help to maintain patient appetite at cumulative radiation doses of 30/50 Gy.     

CAUSE OF IMMEDIATE DEATH BY LARGE DOSES OF BOTULINUS TOXIN

Parenteral introduction of amounts of the culture filtrate of Bacillus botulinus greatly in excess of the minimum lethal dose has been observed to cause the practically immediate death of mice. This result is due to the presence in the filtrates of a chemical poison possessing properties distinct from those of the contained botulinus toxin which itself acts only after a well defined period of incubation. This chemical poison is not neutralized by botulinus antitoxin; it is effective only when large amounts of the culture filtrate are given; it is thermostable, not being destroyed when heated in the autoclave in a sealed tube, though when it is heated in an open container its toxicity diminishes with a coincidental volatilization of basic material. The volatile substance can be identified as ammonia. Death resulting from the injection of comparatively large amounts of ammonium salts (0.1 gm.) is easily distinguished from that due to botulism, both through the character of the symptoms and the absence of an incubation period. However, when the amount of toxic salts injected is smaller (0.01 gm.), the symptoms of poisoning are not so characteristic and death may be delayed long enough to suggest a period of incubation similar to that observed in botulism (Table IV). This circumstance is of importance in connection with the examination of partly decomposed food products in which the presence of botulinus toxin is suspected. As a rule such suspected material is injected in massive doses (0.5 to 1 cc.) in mice. It is conceivable that such spoiled foods may be contaminated with common putrefactive bacteria yielding ammonia during their growth and thus may cause death of the test animals. If in such tests mice passively protected by the preliminary injection of an excess of antitoxin be used in addition to normal animals, the chances of an error in the interpretation of the results will be materially reduced, though not ruled out. Unfortunately for such a procedure, botulinus antitoxin is not readily available, while furthermore, recent findings indicate that it may not always be effective owing to the existence of a group of toxin-producing bacteria very similar to Bacillus botulinus, but not homologous immunologically with either of the known types of the latter. The test of thermostability of the toxic constituents of suspected food may conceivably help to determine the true nature of the poison.     

新疆维吾尔自治区乌鲁木齐市一起肉毒中毒事件调查分析

  目的  通过对新疆维吾尔自治区乌鲁木齐市一起肉毒中毒事件进行调查分析和实验室检测,并采取有效措施预防。  方法  通过查阅就诊记录、访谈相关医生并通过入户调查方式进行现场流行病学调查,采集病例粪便、剩余食物等进行肉毒毒素实验室检测及分型鉴定。  结果  确诊病例2例,均被收治入院。 使用A、B型肉毒抗毒素治疗后, 症状明显缓解。 实验室分离到肉毒梭菌,经荧光定量PCR方法检测携带A型毒素基因,确定为A型肉毒梭菌,小鼠实验检测到A型肉毒毒素。  结论  本次事件是一起由家庭自制豆豉引起的肉毒梭菌中毒,由A型肉毒梭菌污染导致,建议加强居民教育,防止食品制作和储存环节污染。     

Assessment of the microbial contribution to the processing of salted salmon roe (Sujiko)

As the microbial contributions to the processing of salted foods have been little investigated, there remains a possibility that excess sterilization of raw materials for salted foods leads to deterioration in food quality and safety. At a salmon roe (sujiko) processing company, we investigated salted sujiko made identically to commercial products, but that had been processed with or without antibiotics. The antibiotics caused no significant difference in the content of free amino acids, lactic acid or acetic acid. These results show that general aerobic bacteria have no impact on the formation of these flavor compounds.     

Botulinum neurotoxin type E: studies on mechanism of action and on structure-activity relationships

Single chain type E botulinum neurotoxin was isolated from culture fluids of Clostridium botulinum (strain Alaska E-43). The neurotoxin, which migrated as a single band in polyacrylamide gel electrophoresis with sodium dodecylsulfate, had a molecular weight of approximately 147,000. Single chain type E neurotoxin that was exposed to trypsin was converted to a dichain molecule. Pretreatment of the single chain molecule with 1,2-cyclohexanedione, a reagent that selectively modifies arginine residues, inhibited trypsin-induced generation of the dichain molecule. In dose-response experiments (10(-13) to 10(-9) M) on the isolated neuromuscular junction (phrenic nerve-hemidiaphragm preparation), the dichain neurotoxin was approximately two orders of magnitude more potent than the single chain neurotoxin. Neither specie of neurotoxin (1 pmol/mouse, in vivo; 1 X 10(-11) M, in vitro) was very effective in blocking autonomic transmission (vagus nerve-atrium preparation). The neuromuscular blocking action of the dichain molecule was divided into a sequence of three steps. There was an initial binding step that was relatively rapid, little influenced by temperature and which left the neurotoxin partially accessible to the neutralizing effects of antitoxin. There was a translocation step that was temperature dependent, antagonized by ammonium chloride and methylamine hydrochloride and which caused the neurotoxin to become inaccessible to the neutralizing effects of antitoxin. Finally, there was an intracellular lytic step, during which the toxin blocked excitation-secretion coupling.     

Formes graves de botulisme du nouveau-né et du nourrisson : trois observations récentes et algorithme de prise en charge

Botulism rarely involves young children. Food borne botulism is a direct toxin contamination that can affect infants following the ingestion of a food product contaminated by botulinum toxin. Infant botulism occurs after intestinal colonisation by Clostridium botulinium and secondary toxin production in children less than 12 months of age. Both forms lead to a presynaptic blockage of the neuromuscular junction. In its natural course, the disease ultimately resolves completely, but some patients will require ventilatory and nutritional support, thus experiencing intensive care complications. Early administration of intravenous antitoxin has been proved to accelerate recovery, which requires physicians to be aware of this rare disease. Here we report three recent cases of botulism in young children that are especially relevant, and propose guidelines to optimise diagnosis and treatment.     

A clinical case of botulism

A patient with botulism (type E) has been subject to complex therapy, which involved specific serotherapy, infusion therapy, and controlled lung ventilation with the following assisted lung ventilation.