Chapter 134. Botulism (Part 4) ppsx

Botulism Part 4 Botulism: Treatment Patients should be hospitalized and monitored closely, both clinically and by spirometry, pulse oximetry, and measurement of arterial blood gases fo

Chapter 134 Botulism

(Part 4)

Botulism: Treatment

Patients should be hospitalized and monitored closely, both clinically and

by spirometry, pulse oximetry, and measurement of arterial blood gases for incipient respiratory failure Intubation and mechanical ventilation should be

strongly considered when the vital capacity is <30% of predicted, especially when paralysis is progressing rapidly and hypoxemia with absolute or relative hypercarbia is documented (Chap 263) Serial measurements of the maximal static inspiratory pressure may be useful in predicting respiratory failure

In food-borne illness, equine antitoxin should be administered as soon as possible after specimens are obtained for laboratory analysis Treatment should not await laboratory analyses, which may take days The previous trivalent antitoxin preparation (types A, B, and E) is no longer available Instead, a bivalent preparation containing toxin types A and B and an investigational monovalent type E preparation can be obtained The bivalent preparation is administered routinely; monovalent type E antitoxin is given in addition when exposure to type

E toxin is suspected (after seafood ingestion, for example) In the United States, antitoxin as well as help with clinical management and laboratory confirmation are

available at any time from state health departments or from the Centers for

Disease Control and Prevention (CDC; emergency number, 770-488-7100) A limited supply of an investigational heptavalent antitoxin (types A through G)) is maintained by the U.S military for emergency use

After testing for hypersensitivity to horse serum, antitoxin is given as recommended by the CDC; repeated doses are not considered necessary Anaphylaxis and serum sickness are risks inherent in use of the equine product, and desensitization of allergic patients may be required If there is no ileus,

cathartics and enemas may be used to purge the gut of toxin; emetics or gastric lavage can also be used if the time since ingestion is brief (only a few hours) Neither the use of antibiotics to eliminate an intestinal source of possible continued toxin production nor the administration of guanidine hydrochloride and other drugs to reverse paralysis is of proven value

Treatment of infant botulism requires supportive care and administration of human botulism immune globulin, which can be obtained by calling the California Department of Health Services at 510-231-7600 or by following the instructions at www.infantbotulism.org Neither equine antitoxin nor antibiotics have been shown

to be beneficial In wound botulism, equine antitoxin is administered The wound should be thoroughly explored and debrided, and an antibiotic such as penicillin

should be given to eradicate C botulinum from the site, even though the benefit of

this therapy is unproven Results of wound cultures should guide the use of other antibiotics

Botulinum toxins are being employed for a variety of cosmetic and therapeutic purposes, and new uses are being evaluated Generalized botulism-like weakness complicating therapy (iatrogenic botulism) has been reported but is rare

Prognosis

Type A disease is generally more severe than type B, and mortality rates from botulism are higher among patients above age 60 than among younger

patients With improved respiratory and intensive care, the case-fatality rate in food-borne illness has been reduced to ~7.5% and is low in infant botulism as well Artificial respiratory support may be required for months in severe cases Some patients experience residual weakness and autonomic dysfunction for as long as a year after disease onset

Prevention

A pentavalent vaccine (types A through E) is available for use in highly exposed individuals Spores are highly resistant to heat but can be inactivated by exposure to high temperature (116–121°C) and pressure, as in steam sterilizers or pressure cookers used in accordance with the manufacturer's instructions Toxin is heat-labile and can be inactivated by exposure to a temperature of 85°C for 5 min Newly identified cases should be reported immediately to public health authorities

Further Readings

Arnon SS et al: Human botulism immune globulin for the treatment of infant botulism N Engl J Med 354:462, 2006 [PMID: 16452558]

——— et al: Botulinum toxin as a biological weapon, in Bioterrorism:

Guidelines for Medical and Public Health Management, DA Henderson et al

(eds) Chicago, AMA Press, 2002, pp 141–165

Cawthorne A et al: Botulism and preserved green olives Emerg Infect Dis 11:781, 2005 [PMID: 15898180]

Caya JG et al: Clostridium botulinum and the clinical laboratorian: A

detailed review of botulism, including biological warfare ramifications of botulinum toxin Arch Pathol Lab Med 128:653, 2004 [PMID: 15163234]

Centers for Disease Control and Prevention: Botulism from home-canned

bamboo shoots—Nan Province, Thailand MMWR 55:389, 2006

Chertow DS et al: Botulism in 4 adults following cosmetic injections with

an unlicensed highly concentrated botulinum preparation JAMA 206:2476, 2006

Cooper JG et al: Clostridium botulinum: An increasing complication of

heroin misuse Eur J Emerg Med 12:251, 2005 [PMID: 16175065]

Gupta A et al: Adult botulism type F in the United States, 1981-2002 Neurology 65:1694, 2005 [PMID: 16344510]

Lindström M, Korkeala H: Laboratory diagnostics of botulism Clin Microbiol Rev 19:298, 2006

Montecucco C, Molgo J: Botulinal neurotoxins: Revival of an old killer Curr Opin Pharmacol 5:274, 2005 [PMID: 15907915]

Sobel J: Botulism Clin Infect Dis 41:1167, 2005 [PMID: 16163636]

Bibliography

Akbulut D et al: Improvement in laboratory diagnosis of wound botulism and tetanus among injecting illicit-drug users by use of real-time PCR assays for neurotoxin gene fragments J Clin Microbiol 43:4342, 2005 [PMID: 16145075]

Barr JR et al: Botulinum neurotoxin detection and differentiation by mass spectrometry Emerg Infect Dis 11:157, 2005

Centers for Disease Control and Prevention: Botulism in the United States, 1899-1996: Handbook for epidemiologists, clinicians, and laboratory workers Atlanta, CDC, 1998 (http://www.bt.cdc.gov/agent/botulism/)

Cherington M: Botulism: Update and review Semin Neurol 24:155, 2004

[PMID: 15257512]

Fox CK et al: Recent advances in infant botulism Pediatr Neurol 34:149,

2005

Grumelli C et al: Internalization and mechanism of action of clostridial toxins in neurons Neurotoxicology 26:761, 2005 [PMID: 15925409]

Hatheway CL: Botulism: The present status of disease Curr Top Microbiol Immunol 195:55, 1995 [PMID: 8542759]

Horowitz BZ: Botulinum toxin Crit Care Clin 21:825, 2005 [PMID: 16168317]

Pascuzzi RM: Pearls and pitfalls in the diagnosis and management of neuromuscular junction disorders Semin Neurol 21:425, 2001 [PMID: 11774058]

Sandrock CE, Murin S: Clinical predictors of respiratory failure and long term outcome in black tar heroin–associated wound botulism Chest 120:562,

2002

Shapiro RL et al: Botulism in the United States: A clinical and epidemiologic review Ann Intern Med 129:221, 1998 [PMID: 9696731]

Smith LDS, Sugiyama H: Botulism: The Organism, Its Toxins, the Disease,

2d ed Springfield, IL, Charles C Thomas, 1988

Sobel J: Foodborne botulism in the United States, 1990-2000 Emerg Infect Dis 10:1606, 2004 [PMID: 15498163]

Werner SB et al: Wound botulism in California, 1951–1998: Recent epidemic in heroin injectors Clin Infect Dis 31:1018, 2000 [PMID: 11049786]