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.     

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.     

Cockles and mussels,alive, alive,oh—The role of bivalve molluscs as transmission vehicles for human norovirus infections

Human noroviruses are recognized as the leading worldwide cause of sporadic and epidemic viral gastroenteritis, causing morbidity and mortality in impoverished developing countries and engendering enormous economic losses in developed countries. Transmitted faecal‐orally, either via person‐to‐person contact, or by consumption of contaminated foods or water, norovirus outbreaks are often reported in institutional settings or in the context of communal dining. Bivalve molluscs, which accumulate noroviruses via filter feeding and are often eaten raw or insufficiently cooked, are a common food vehicle implicated in gastroenteritis outbreaks. The involvement of bivalve molluscs in norovirus outbreaks and epidemiology over the past two decades are reviewed. The authors describe how their physiology of filter feeding can render them concentrated vehicles of norovirus contamination in polluted environments and how high viral loads persist in molluscs even after application of depuration practices and typical food preparation steps. The global prevalence of noroviruses in bivalve molluscs as detected by different monitoring efforts is determined and the various methods currently utilized for norovirus extraction and detection from bivalve matrices described. An overview of gastroenteritis outbreaks affirmatively associated with norovirus‐contaminated bivalve molluscs as reported in the past 18 years is also provided. Strategies for risk reduction in shellfish contamination and subsequent human infection are discussed.     

Advances in Studies on Hepatitis E Virus

Hepatitis E virus(HEV) is transmitted mainly through food and water sources. HEV is a major public health problem faced by developing countries. HEV causes large outbreaks of hepatitis E(HE) or acute sporadic infection. HEV can also lead to chronic infection. HEV mainly affects the young, middle-aged people, and pregnant women, who especially display high rates of infection. This study reviews HE while considering its biological characteristics, clinical symptoms, epidemic characteristics, vaccine, and detection methods.     

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.     

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.     

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.     

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 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.     

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.     

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.     

Outbreaks of Clade 2.3.4.4 H5N8 highly pathogenic avian influenza in 2018 in the northern regions of South Africa were unrelated to those of 2017

Asian‐origin H5N8 highly pathogenic avian influenza (HPAI) viruses of the H5 Goose/Guangdong/96 lineage, clade 2.3.4.4 group B, reached South Africa by June 2017. By the end of that year, 5.4 million layers and broiler chickens died or were culled, with total losses in the poultry industry estimated at US$ 140 million, and thousands of exotic birds in zoological collections, endangered endemic species and backyard poultry and pet birds also perished. The 2017 H5N8 HPAI outbreaks were characterized by two distinct spatial clusters, each associated with specific reassortant viral genotypes. Genotypes 1, 2, 3 and 5 were restricted to the northern regions, spanning the provinces of Limpopo, Gauteng, North West, Mpumalanga, KwaZulu‐Natal and Free State. The second, much larger cluster of outbreaks was in the south, in the Western and Eastern Cape provinces, wherein 2017 and 2018 outbreaks were caused solely by genotype 4. The last confirmed case of H5N8 HPAI in the northern region in 2017 was in early October, and the viruses seemed to disappear over the summer. However, starting in mid‐February 2018, H5N8 HPAI outbreaks resurged in the north. Viruses from two of the eight outbreaks were sequenced, one from an outbreak in quails (Coturnix japonica) in the North West Province, and another from commercial pullets in the Gauteng province. Phylogenetic analysis identified the viruses as a distinct sixth genotype that was most likely a new introduction to South Africa in early 2018.     

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.     

Tracing the origins of genotype VIIh Newcastle disease in southern Africa

It is widely accepted that Newcastle disease is endemic in most African countries, but little attention has been afforded to establishing the sources and frequency of the introductions of exotic strains. Newcastle disease outbreaks have a high cost in Africa, particularly on rural livelihoods. Genotype VII h emerged in South‐East Asia and has since caused serious outbreaks in poultry in Malaysia, Indonesia, southern China, Vietnam and Cambodia. Genotype VII h reached the African continent in 2011, with the first outbreaks reported in Mozambique. Here, we used a combination of phylogenetic evidence, molecular dating and epidemiological reports to trace the origins and spread of subgenotype VII h Newcastle disease in southern Africa. We determined that the infection spread northwards through Mozambique, and then into the poultry of the north‐eastern provinces of Zimbabwe. From Mozambique, it also reached neighbouring Malawi and Zambia. In Zimbabwe, the disease spread southward towards South Africa and Botswana, causing outbreaks in backyard chickens in early‐to‐mid 2013. In August 2013, the disease entered South Africa's large commercial industry, and the entire country was infected within a year, likely through fomites and the movements of cull chickens. Illegal poultry trading or infected waste from ships and not wild migratory birds was the likely source of the introduction to Mozambique in 2011.     

Foot‐and‐Mouth Disease Vaccination in South Sudan: Benefit–Cost Analysis and Livelihoods Impact

A benefit–cost analysis of vaccination for foot‐and‐mouth disease (FMD) was conducted in an area of South Sudan, which due to chronic conflict, had been subject to large‐scale humanitarian assistance for many years. The study used participatory epidemiology (PE) methods to estimate the prevalence and mortality of acute and chronic FMD in different age groups of cattle, and the reduction in milk off‐take in cows affected by FMD. The benefit–cost of FMD vaccination was 11.5. Losses due to the chronic form of FMD accounted for 28.2% of total FMD losses, indicating that future benefit–cost analyses for FMD control in pastoral and agropastoral areas of Africa need to consider losses caused by chronic disease. Participatory epidemiological methods were also used to assess the importance of milk in the diet of Nuer agropastoralists, and seasonal variations in diet in relation to cattle movements and FMD outbreaks. Marked seasonal variation in diet included a ‘hunger gap’ period during which households were highly dependent on milk as their main source of food. Outbreaks of FMD occurred immediately before this period of milk dependency, with chronic losses extending through this period and affecting human food security. The paper discusses the need and feasibility of mass vaccination and strategic vaccination for FMD in South Sudan. The paper also discusses the value of combining conventional benefit–cost analysis with livelihoods analysis to inform disease control efforts and funding commitments in humanitarian contexts.     

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.     

Molecular phylogenetics of Newcastle disease viruses isolated from vaccinated flocks during outbreaks in Southern India reveals circulation of a novel sub‐genotype

Newcastle disease (ND) is an economically important, contagious poultry viral disease reported across the globe. In India, ND is endemic and episodes of ND outbreaks despite strict vaccinations are not uncommon. We isolated and characterized seven ND viruses from vaccinated commercial poultry farms during severe disease outbreaks in Tamil Nadu, in Southern India, between April 2015 and June 2016. All the seven isolates were categorized as virulent by mean death time (48–54 hr) in embryonated chicken eggs. Also, their sequences carried the virulence signature of multi‐basic amino acid residues in their fusion protein cleavage site (RRQ/RR/KRF). Phylogenetic and evolutionary distance analyses revealed circulation of a novel sub‐genotype of genotype XIII, class II ND viruses, herein proposed as sub‐genotype XIIIe. The genetic divergence between the circulating virulent strains and the vaccine strains could possibly explain the disease outbreak in the vaccinated flocks. Further, our study signifies the need to implement routine epidemiological surveillance and to revisit the current vaccination program.     

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.