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.     

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.     

Acute paralysis following “a bad potato”: A case of botulism

PURPOSE: Intensivists often encounter patients with respiratory failure as a result of neuromuscular disease, however, acute neuro-muscular syndromes are less common. We present a case of food borne Clostridium botulism and discuss the diagnostic and therapeutic considerations. CLINICAL FINDINGS: A 35-yr-old healthy male presented with abdominal pain and blurred vision 12 hr after ingesting a "bad" potato. During the next 17 hr, the patient demonstrated a gradual descending paralysis which ultimately resulted in no cranial nerve function and 0/5 strength in all extremities. Sensation was intact. The patient required intubation and mechanical ventilation. His blood count, biochemical profile, computerized tomography and magnetic resonance imaging of the head were normal. A lumbar puncture revealed no abnormalities. Due to the rapid deterioration and presentation of 'descending' paralysis, botulism was suspected. The patient was treated empirically with botulinum anti-toxin. Samples of blood, stool and gastric contents were cultured for the presence of Clostridium botulinum and its toxin and these tests were positive for botulinum toxin A 12 days later. The patient's neuromuscular function gradually improved over a prolonged period of time. Six and one-half months after his initial presentation, the patient was discharged home after completing an aggressive rehabilitation program. CONCLUSIONS: Botulism is a rare syndrome and presents as an acute, afebrile, descending paralysis beginning with the cranial nerves. If suspected, botulinum anti-toxin should be considered, particularly within the first 24 hr of onset of symptoms. Confirmation of the presence of botulinum requires days therefore the diagnosis and management rely on history and physical examination.     

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.     

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.     

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, 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.     

A case of type A botulism

The neurotoxin produced by Clostridium botulinum, is responsible for botulism. The clinical signs are digestive disorders, pupillar alterations, and peripheral muscular weakness. The failure of thoracic muscles is responsible for the severity of botulism. We describe a case of a 74 year old woman who presented a severe form of botulism, requiring a prolonged intensive care unit stay.     

A Case of Foul Genital Odor Treated with Botulinum Toxin A

BACKGROUND: Genital odor is an uncommon condition characterized by an offensive and malodorous smell in the genital area. Although the etiology of foul genital odor is multifactorial, an important cause is sweat secretion and decomposition of sweat components by bacteria. Different methods are effective in reducing body odor secondary to bromhidrosis. Conservative methods only act for a short period of time, and more invasive surgical methods carry risk of complications or are inapplicable for the genital region. METHODS: A patient with localized foul odor in the genital hair bearing area was treated with botulinum toxin A. RESULTS: Botulinum toxin A was effective in creating an odorless and anhydrous response in the genital region, and no major adverse effects were noted during a follow-up of 9 months after injection. CONCLUSION: Local injection of botulinum toxin A appears to be a useful treatment for foul genital odor related to sweat glands activity.     

Botulinum Toxin A for Aesthetic Contouring of Enlarged Medial Gastrocnemius Muscle

BACKGROUND: Oversized, muscular calves can cause psychological stress in women. Botulinum toxin A has been used in the treatment of benign masseteric hypertrophy with correction of the squared facial appearance. It is believed that botulinum toxin might also be effective in reducing enlarged calf muscles. OBJECTIVE: This study was performed to investigate the effect of botulinum toxin A in reducing enlarged medial gastrocnemius muscles in volunteers with muscular legs. METHODS: Botulinum toxin A of 32, 48, or 72 U was injected in each medial head of the gastrocnemius muscle in six women. Clinical photography was taken and the leg circumferences were measured. The functional evaluations were performed by examining range of joint motion and motor and sensory examination. RESULTS: All of the enrolled subjects showed a reduction in the medial gastrocnemius muscle after the botulinum toxin injection. The reduction in medial calf was noticed even after 1 week and the effect of was well maintained for 6 months. Leg contouring was obtained by the botulinum toxin treatment. The middle leg circumference showed a slight decrease in five subjects. No functional disabilities were observed. CONCLUSION: Botulinum toxin A can be used to contour the aesthetic enlargement of the medial gastrocnemius muscle with slight reduction in volume. Botulinum toxin-induced atrophy of the muscle caused no functional disabilities and the clinical improvement was well maintained for 6 months after the botulinum toxin A injection.     

Improving Patient Retention After Botulinum Toxin Type A Treatment

BACKGROUND: Botulinum toxin treatments have been associated with consistently high patient satisfaction rates, but calculation of patient retention rates is not routinely performed. Retention measurements serve as critical indicators of clinical performance and can be optimized by evaluation of current office policies and implementation of strategies to improve patient retention. PURPOSE: To investigate the reasons patients discontinue botulinum toxin treatments and to evaluate the effect of a single intervention intended to improve patient retention. METHODS: A retrospective chart review was performed of all patients who received botulinum toxin injections in a private cosmetic dermatology practice over a 2-year time period to determine the patient retention rate. Patients who had discontinued botulinum toxin treatment after a single session were surveyed to discern their reasons for terminating treatment. A change in office policy was instituted wherein all patients who received their first botulinum toxin treatment were required to undergo a 2-week post-treatment evaluation to determine treatment effect and to receive touch-up treatment as necessary. Retention rates were calculated over the 1-year period immediately after initiation of the new policy. RESULTS: The initial patient retention rate was 55%. The most common reasons cited for discontinuance of botulinum toxin treatments were procedural cost, patient failure to re-schedule, perceived lack of product longevity, and clinical effect falling short of expectations. After initiation of the mandatory 2-week post-treatment office evaluation, a 67% patient retention rate was achieved. CONCLUSIONS: Managing patient expectations of botulinum toxin treatments and mandatory post-treatment appointments for evaluation of the initial procedure increase the patient retention rate.     

Role for botulinum toxin in back pain treatment in adults with cerebral palsy: report of a case

OBJECTIVE: To report a case illustrating the usefulness of botulinum toxin A in the treatment of spinal dystonia responsible for low back pain and postural disorders. METHODS: Critical appraisal of a case report. CASE REPORT: A young woman with cerebral palsy had lumbar paraspinal muscle dystonia responsible for pain and hyperlordosis unresponsive to oral medications for muscle spasm. Botulinum toxin A (Botox(R), 200 U) was injected into the paraspinal muscles at six sites, to good effect. DISCUSSION: The few reported cases consistently show a favorable effect of local botulinum toxin A injections in patients with painful paraspinal muscle dystonia related to neurological disease or chronic low back pain. CONCLUSION: Botulinum toxin A may be a useful treatment for incapacitating painful dystonia of the paraspinal muscles. This treatment improves posture in the sitting position and facilitates the fitting of orthotic devices. Furthermore, botulinum toxin A treatment may help to determine whether an intrathecal baclofen test is in order.     

Treatment of chronic radial epicondylitis with botulinum toxin A. A double-blind, placebo-controlled, randomized multicenter study

BACKGROUND: Radial epicondylitis (tennis elbow) is the most frequent type of myotendinosis. Patients can experience substantial loss of function, especially when this condition becomes chronic. A successful therapy has not yet been established. A preliminary study of injections of botulinum toxin A in patients with chronic epicondylitis has shown promising results. METHODS: In the present prospective, controlled, double-blinded clinical trial, 130 patients were examined at sixteen study centers. A single injection of botulinum toxin A into the painful origin of the forearm extensor muscles was performed. Follow-up examinations were performed at two, six, twelve, and eighteen weeks. Clinical findings were documented with use of a new clinical pain score and with a visual analogue scale. A global assessment of the result of treatment was also provided by the patient and the attending doctor. Strength of extension of the third finger and the wrist was evaluated with use of the Brunner method, and grip strength (fist closure strength) was measured with a vigorimeter. RESULTS: The group treated with botulinum toxin A was found to have a significant improvement in the clinical findings, compared with those in the placebo group, as early as the second week after injection (p = 0.003). Subjective general assessment also showed improvement in that group, compared with the placebo group, at six weeks (p = 0.001) and at the time of the final examination (at eighteen weeks) (p = 0.001). There was a consistent increase in fist closure strength in both the group treated with botulinum toxin A and the control group, but there was no significant difference between groups. As was expected as a side effect, extension of the third finger was observed to be significantly weakened at two weeks but this complication had completely resolved at eighteen weeks. CONCLUSIONS: We concluded that local injection of botulinum toxin A is a beneficial treatment for radial epicondylitis (tennis elbow). The treatment can be performed in an outpatient setting and does not impair the patient's ability to work.     

Festoon Formation After Infraorbital Botulinum A Toxin: A Case Report

BACKGROUND: An injection of the lateral canthus and infraorbital fold is commonly used to soften wrinkles and widen the eye. OBJECTIVE: To illustrate a case report of festooning and to hypothesize as to its cause. METHODS: A 56-year-old man developed festooning of the infraocular area after injection of botulinum toxin A. RESULTS: Prior lower lid blepharoplasty with separation of the infraorbital orbicularis oculi muscle may have weakened the muscle enough to cause festooning with further weakening of the muscle through botulinum toxin A injection. CONCLUSION: Caution must be exercised when performing infraocular injection of botulinum toxin A in patients with prior transtarsal lower lid blepharoplasty.     

Botulinum Toxin Use as an Adjunctive Modality in a Patient with Multiple Flexor Tendon Ruptures

Botulinum toxin A has been described in treatment protocols for several disease processes, from primary axillary hyperhydorosis to esophageal dysfunction. It is best known for its use in plastic and dermatological practices. Botulinum toxin has a straightforward mechanism of action. The toxin inhibits acetylcholine release at the neuromuscular junction causing a chemical denervation, which ceases contractions of the muscle. With its minimal side effect profile, botulinum toxin should be considered when muscle spasm is a detriment. This case involves an injury to the hand of a patient with a history of intermittent diffuse muscle spasms. Subsequently, due to the patient's previous upper extremity muscle spasms, repeated flexor tendon repair ruptures of the index finger occurred until botulinum toxin was administered to the offending muscle. The patient has not required any additional surgical interventions for the repaired tendon and is now actively flexing all digits. This case report demonstrates how botulinum toxin can be used in a clinical scenario when decreased muscle activity is desired to promote tendon healing.     

A 型肉毒素治疗面部皱纹的美容效果

为探究A型肉毒素治疗面部皱纹的美容效果，本研究选取2021年1月-2023年1月于我院行面部 皱纹修复的50例患者为研究对象，所有患者均采用A型肉毒素进行治疗，观察临床治疗效果和不良反应发 生情况。结果显示，治疗总有效率高达98.00%，不良反应发生率较低，仅为4.00%。可见，在面部皱纹治疗 中，应用A型肉毒素治疗效果肯定，治疗过程安全，值得临床应用。     

Botulinum toxin in the management of lower urinary tract dysfunction: contemporary update

PURPOSE OF REVIEW: To review the most recent experience concerning the application of botulinum toxin in the human lower urinary tract. RECENT FINDINGS: Botulinum toxin was initially applied in the bladder of patients with spinal neurogenic detrusor overactivity and urinary incontinence, or in the urethra in cases of detrusor external sphincter dyssynergia. A large multicentric European study fully confirmed the initial expectancy in the former condition. In addition, the application of botulinum toxin was extended to the treatment of other urological disorders including non-neurogenic detrusor overactivity, non-relaxing urethral sphincter and detrusor underactivity. Interesting reports on the injection of botulinum toxin into the prostate of patients with benign prostatic hyperplasia are also reviewed. SUMMARY: Bladder injection of botulinum toxin is not yet an approved treatment for lower urinary tract dysfunction. Nevertheless, available data suggest that in the near future the toxin will become a standard therapeutic option in incontinent patients with neurogenic and non-neurogenic forms of overactive bladder, who do not respond to or do not tolerate anticholinergic medication. In addition, it might be expected that urethral botulinum toxin injections improve bladder emptying in patients with dysfunctional voiding problems besides detrusor external sphincter dyssynergia.     

Botulinum toxin type A in the healing of chronic lesion following bilateral spasticity of gluteus muscle

Use of botulinum toxin is expanding as the clinical studies demonstrate new potential therapeutic applications. In rehabilitation, botulinum toxin is above all used as adjunct therapy for the treatment of spasticity, but it may prove useful for other atypical clinical situations. A 17‐year‐old man had a sub‐arachnoid haemorrhage following the rupture of cerebral aneurism. The patient presented gluteus maximus and medius bilaterally spasticity that produced a chronic lesion in the intergluteal cleft, a flexed wrist and a flexed elbow. As treatment for this spasticity, a total of 100 U botulinum toxin type A were injected into the glutei muscles. This treatment allowed for application of topical medication and subsequently, chronic lesion healing. Botulinum toxin A may be an important therapeutic aid for clinicians faced with treating persistent pathological conditions caused by spasticity.     

Botulinum toxin type A for the treatment of lower urinary tract disorders

Many papers report the clinical success of botulinum toxin A as a method of management of various bladder dysfunctions. The rationale was that botulinum toxin A was able to block the presynaptic release of acetylcholine from the parasympathetic efferent nerve. The efficacy might result not only from an inhibitory effect on detrusor muscle, but also some effects might be mediated by altering the afferent nerve input. This systematic literature review discusses the efficacy and safety of botulinum toxin A therapy for idiopathic detrusor overactivity, neurogenic detrusor overactivity, interstitial cystitis/painful bladder syndrome and benign prostatic hyperplasia. The information was gathered from a PubMed literature research for abstracts from recent urological meetings. Injection of botulinum toxin A appears to have a positive therapeutic effect in multiple urological conditions, such as refractory idiopathic detrusor overactivity, neurogenic detrusor overactivity, interstitial cystitis/painful bladder syndrome and benign prostatic hyperplasia. Because the United States Food and Drug Administration has approved botulinum toxin A (Botox) for injection for the treatment of urinary incontinence as a result of neurogenic detrusor overactivity (e.g. spinal cord injury, multiple sclerosis) in adults who have an inadequate response to or are intolerant of an ant cholinergic medication, the use of botulinum toxin A will spread and be a more familiar therapy in the urological arena. However, further robust evidence should be awaited. We will discuss the current use of this agent within the urological field.     

Antibody-Induced Failure of Botulinum Toxin Type A Therapy in a Patient with Masseteric Hypertrophy

BACKGROUND With the expanding use of botulinum toxin, much concern about the antibody against botulinum toxin is arising. Unlike neurologic indications such as cervical dystonia, antibody-induced failure of botulinum toxin therapy has never been reported in the cosmetic field.
OBJECTIVE The objective was to describe a case of an antibody-induced failure of botulinum toxin type A (BTX-A) therapy (BOTOX, Allergan, Inc.) that occurred in a patient with masseteric hypertrophy.
METHODS AND MATERIALS We present a 20-year-old girl who developed antibody-induced therapy failure after the fourth injection series. Sixty units of toxin was injected at each series and the intertreatment interval was four to five months.
RESULTS Frontalis test revealed no paresis of muscle after a unilateral injection of BTX-A. Circulating antibodies against BTX-A were detected by indirect enzyme-linked immunosorbent assay and mouse protection assay.
CONCLUSION This case is unique in that, first, immunoresistance developed in a patient of cosmetic indication where only a small dose of BTX-A was administered and, second, antibodies developed on the so-called new formulation of BOTOX. Our case alerts cosmetic surgeons to the importance of antibody against the botulinum toxin.