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.     

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.     

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.     

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...     

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.     

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.     

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.     

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.     

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。     

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.     

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.     

Prolonged resuscitation: a case report

This report illustrates a case of prolonged resuscitation (without hypothermia) with a return of spontaneous circulation (ROSC) after 1 h of resuscitation in a hospital car park and emergency department. Coronary artery stenting was achieved 2 h and 45 min after collapse. Following a 12-week stay in hospital the patient was discharged home making a full recovery within 12 months. Issues regarding prolonged resuscitation and the key predictors of survival are discussed.     

Pancreatitis associated with simvastatin plus fenofibrate

OBJECTIVE: To report a case of acute necrotizing pancreatitis associated with simvastatin and fenofibrate use. CASE SUMMARY: A 70-year-old white man presenting with rapid onset of abdominal pain, nausea, and vomiting was diagnosed with acute pancreatitis. On bowel rest, his condition deteriorated secondary to systemic inflammatory response syndrome, and he was transferred to a tertiary hospital's intensive care unit (ICU). He had been taking fenofibrate for 1 year; 6 months prior to this admission, he had been taking simvastatin 3 days of the week and fenofibrate the other 4 days of the week. The pancreatic tissue became necrotic, requiring surgical debridement. After a hospital stay of 121 days, including multiple ICU admissions, the patient died secondary to a bowel perforation. DISCUSSION: Although idiopathic pancreatitis cannot be ruled out in this patient, no causes of pancreatitis were identified other than drug induced. Five cases of acute pancreatitis caused by simvastatin have been reported; no case reports were found for fenofibrate. The onset of pancreatitis relative to the duration of therapy with simvastatin supports this medication as a possible cause of the pancreatitis. CONCLUSIONS: Drug-induced pancreatitis is well established as an adverse effect of some medications, although most are substantiated only with case reports. Given the absence of other apparent causes, simvastatin and fenofibrate should be considered as possible causes of pancreatitis in this patient.     

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.     

New targets in the search for preventive and therapeutic agents for botulism

Botulism is a severe neuroparalytic disease resulting from exposure to one of the most poisonous toxins to humans. Because of this high potency and the use of toxins as biological weapons, botulism is a public health concern and each case represents an emergency. Current therapy involves respiratory supportive care and anti-toxins administration. As a preventive measure, vaccination against toxins represents an effective strategy but is undesirable due the rarity of botulism and the effectiveness of toxins in treating several neuromuscular disorders. This paper summarizes the current issues in botulism treatment and prevention, highlighting the challenge for future researches.     

A foodborne outbreak causing a cholinergic syndrome

We report a foodborne outbreak causing a cholinergic syndrome in three members of a family. The clinical presentation was characterized by nausea, vomiting, abdominal pain, and weakness. Physical examination revealed evidence of peripheral motor weakness and decreased level of consciousness in all three patients. Bradycardia, hypotension, and seizures occurred in two patients. Although initial therapy included administration of antitoxin for possible botulism, subsequent investigation revealed evidence of accidental organophosphate (fensulfothion) poisoning. The ubiquitous use of organophosphates as agricultural and household insecticides has ensured their continuing importance as causes of foodborne poisoning in both developed and developing countries. Physicians must remain alert to the possibility of non-bacterial causes of foodborne outbreaks in order to initiate prompt and appropriate investigations and specific therapy.     

THE EFFECT OF ANESTHESIA AND OF SEDATIVES ON THE SERUM THERAPY OF EXPERIMENTAL BOTULISM

When guinea pigs are fed large amounts of botulinus toxin, they develop symptoms of intoxication within 6 hours and die usually within 12 hours after the feeding of toxin. If very large amounts of toxin are introduced intraperitoneally, the animals may show symptoms of intoxication at the end of the 1st hour and die usually within 2 hours following the administration of toxin. If these animals are placed under anesthesia following the administration of toxin, the intoxication proceeds much more slowly. Anesthesia, by ether, is effective in this manner whether the toxin is given per os or intraperitoneally. The life of guinea pigs kept under ether after the administration of lethal amounts of toxin is prolonged by a period approximately equal to that during which the administration of the anesthetic is continued. When anesthesia is discontinued, the intoxication proceeds at its usual rate. It appears, therefore, that administration of ether delays the rate of intoxication but does not alter the toxin or the nature of the mechanism of intoxication. Anesthesia thus delays the progress of intoxication not only when administered immediately after the intake of toxin, but when administered much later after the intoxication has already progressed far enough to cause definite objective symptoms of poisoning. At this late stage of intoxication, the unsupported serum therapy of botulism in guinea pigs usually remains without effect. If, however, the animals are anesthetized at this time and kept under the influence of ether for some time, antitoxin therapy becomes effective. Indeed the antitoxin treatment can be delayed further for several hours, provided the animal is kept under anesthesia during the interval. Results of a similar nature were obtained with luminal sodium, nitrous oxide-oxygen mixture, and morphine used in place of ether. In view of the fact that the published data indicate that botulinus antitoxin has thus far failed to give beneficial results in the treatment of botulism in human beings because, as it would seem, of the rapid progress of intoxication, any method of delaying the progress of intoxication to supplement the antitoxin therapy deserves consideration.     

Accessing residential care from an acute hospital: can we be more efficient?

Hospitalized patients who require admission to residential care are often thought to make prolonged and inappropriate use of hospital resources. There are no Australian data on the factors that contribute to length of hospital stay for such patients. The aim of this study was to determine the timing of critical steps in discharge planning for hospitalized patients who need residential care. We prospectively audited 100 consecutive referrals to an Aged Care Assessment Team (ACAT) from one acute hospital in South Australia. Case notes were examined to determine the timings of critical events in discharge planning. We found 47% of patients were discharged to a nursing home, 16% to a hostel, 11% died, 10% returned home and 16% went to another facility. The average length of hospital stay was 27.2 days, and an average of 8.4 days elapsed before a decision to seek residential care was first recorded. A further 4.5 days elapsed before ACAT referral, 4.6 days before ACAT approval and 9.7 days before a residential care bed became available. We conclude that people admitted to our hospital from the community and who subsequently need residential care, spend 36% of their stay awaiting a residential care bed. Most of their hospital stay has elapsed before residential care is considered necessary and referral and approval processes have been activated. Strategies to reduce length of stay should perhaps focus on the earlier recognition of the need for residential care and accelerated referral and assessment processes. Earlier involvement by social work and occupational therapy should be considered.