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IN THE NAME OF GOD B.Khodabakhshi
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Presented by B.Khodabakhshi 2009
Botulism Presented by B.Khodabakhshi 2009 B.Khodabakhshi
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Introduction: Botulism results from protein neurotoxin
Similar to tetanus toxin Cost of care was estimated ,340,000$ in 1989 Have 5 clinical form: A-food born B-intestinal botulism B1-infantile B2-adult type C - wound botulism D – Inhalation ,(bioterrorism) E – Iatrogenic ,(cosmetic ) B.Khodabakhshi
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Botulinum Toxin Very potent Acts at the Neuromuscular Junction
1 microgram kill 10 people 250 grams kill all the people on earth 1 gram aerosolized will kill potentially 1 million people Acts at the Neuromuscular Junction Prevents release of acetylcholine from alpha motor neurons Muscles cannot receive signals telling to contract Flaccid Paralysis B.Khodabakhshi
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Hx : Botulism derives from latin word ,botulus or sausage
In 1820 Kener diagnosed relation between sausage and paralytic illness of 230 pt in Germany 1897 Ermenger described botulism as now B.Khodabakhshi
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Toxicology: Toxin A-G but only A, B, E, F produce human disease
C ,D animal disease C2 cytotoxin, not neurotoxin G no natural disease B.Khodabakhshi
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Neurotoxins Neurotoxin A B C D E F G Human X Horses Cattle Sheep Dogs
Avian Mink & Ferret This table summarizes the most common neurotoxin type affecting the various species affected by C. botulinum. All types of botulinum toxins produce the same clinical signs; however, the toxin type is important if antiserum is used for treatment. Type G has been isolated from soil and autopsy specimens but an etiologic role has not been established. Type E outbreaks are usually related to fish, seafood and meat from marine mammals. B.Khodabakhshi
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Microbiology: G+ ,strict anaerobe, with sub terminal spore.
C .Boyulinum, C.Botyricum, C.Baratii Create spore that can remain dormant 30 year or more C. botulinum spore is distributed worldwide, marine & soil environment It tolerated 100ºc/1 atm/several hours, but not in pressure cooker For non proteolytic activity isn't changing food appearance B.Khodabakhshi
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Epidemiology In U.S., average 110 cases each year
Approximately 25% food-borne Approximately 72% infant form Remainder wound form Infective dose- few nanograms All forms fatal and a medical emergency In the US, there are on average 110 cases of botulism per year. Typically about 25% are food-borne related illnesses. Approximately 72% are the infant botulism form and the remainder are wound related. In 1995, the reported case-fatality rate for botulism cases was 5-10%. B.Khodabakhshi
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Epidemiology: A is more common in west USA
B is more common in east USA Type E have fish source Wound botulism ,A or B Infant A ,B ,F (honey) Unknown origin A ,B, F Foodborn is in outbreak B.Khodabakhshi
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Epidemiology (con..) Home canned vegetable and fruit and fish are more source ,condiment, green beans, beets, corn, baked potatoes, chopped garlic in oil, Chile peppers, tomatoes; type A In Alaskan native & ( torkman ) ,fish fermented In china bean fermented Ph of implicated food is > 4.6 Case fatality rate is from %(>60yr) Inhalation botulism doesn’t occur in nature It’s bioterrorism weapon B.Khodabakhshi
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110 100 90 80 70 60 50 40 30 20 10 Reported Cases This graph depicts the trends of foodborne botulism cases in the U.S. from In 1983, 28 persons in Illinois obtained food-borne botulism from a batch of sautéed onions. Twelve required ventilator support, however no deaths occurred (MMWR 1984:33(2):22-23). During , Alaska recorded 226 cases of food-borne botulism from 114 outbreaks. All were Alaska Natives and were associated with eating fermented foods. In 1994, an outbreak at a Greek restaurant in Texas affected 30 persons from improperly stored foil-wrapped baked potatoes. The 2001 Texas outbreak resulted in 39 cases of foodborne botulism from persons eating commercially produced chili sauce that had been improperly stored. Overall botulism is a rare disease, but it can be fatal and every case of botulism is treated as a public health emergency. Graph from the Summary of Notifiable Diseases 2002, CDC website. Year MMWR B.Khodabakhshi
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Pathogenesis: Toxin after adsorbing in duodenum & jejunum with blood stream reaches to peripheral cholinergic synapses including neuromuscular junctions In synapses :toxin prevents the release of acetylcholine This process results for flaccid paralysis of motor neurons & autonomic dysfunction This process is irreversible B.Khodabakhshi
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Pathogenesis (con..) No CNS involvement
Peripheral cholinergic nerve terminals, A- N.M.J B- post ganglionic parasympathetic 1 – binding with heavy chain 2 – internalization in endocytic vesicle 3 – translocation to cytosole 4 – proteolysis 5 – blockage of acetylcholine realease B.Khodabakhshi
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This figure, "Mechanism of Action of Botulinum Toxin," from the B.Khodabakhshi
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Clinical manifestations:
Acute bilateral cranial neuropathies with symmetrical descending weakness B.Khodabakhshi
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Clinical manifestations (con..)
No fever Symmetrical [ difference with polio] Pt is responsive PR is normal or slow NO sensory deficit (difference with GBS ) B.Khodabakhshi
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Clinical manifestations (con..)
Incubation period 18 – 36 hr Nausea, dry mouth , diarrhea or constipation Symmetric descending neuropathy Cranial neuropathy that begin with eyes Blurred vision (pupillary dysfunction & 3,4,6 nerve paralysis ptosis Dysphagia, dysarthria, diplopia ,hypoglossal weakness Respiratory failure [glot and diaphragm] B.Khodabakhshi
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Clinical manifestations (con..)
Pt need to mechanical ventilation for mean period 58 days Autonomic problems, gastrointestinal dysfunction ,alteration in heart rate, hypothermia & urinary retention Fixed mid dilated or dilated pupil occur in < 50% and doesn’t R/O botulism B.Khodabakhshi
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Clinical manifestations (con..)
Recovery begin after mean 50 day, progress up to 3 month and complete up to 1 yr Some pshychological dysfunctions maybe remain DTR normal or few decreased Requires the sprouting of new nerve terminals B.Khodabakhshi
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Clinical Manifestations
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Infant Botulism Most common form in U.S. Spore ingestion
Germinate then toxin released and colonize large intestine Infants < 1 year old 94% < 6 months old Spores from varied sources Honey, food, dust, corn syrup The most common form of human botulism occurs in infants. Annual incidence in the US is two cases per 100,000 live births. Spores are ingested, germinate, then release their toxin and colonize the large intestine. It occurs predominantly in infants less than 1 year old (94% are less than 6 months old). The spores are obtained from various sources such as honey, food, dust, and corn syrup. B.Khodabakhshi
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Clinical manifestations (con..)
Infant botulism Feeding difficulties Hypotonia Increased drooling Weak cry Upper airway obstruction maybe initial sign B.Khodabakhshi
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Infant Clinical Signs Constipation Lethargy Poor feeding Weak cry
Bulbar palsies Failure to thrive Children less than 1 year of age with the following clinical signs should be suspected of infant botulism. Constipation, lethargy, poor feeding, weak cry, bulbar palsies, failure to thrive, and progressive weakness. This can lead to impaired respiration and sometimes death if not treated promptly. The child in this picture is too weak to hold up its head as noted by the limp appearance of the neck and arms. It was an infant case of botulism. 72% of natural botulism cases occur in children under 1 year of age. California Department of Health Services B.Khodabakhshi
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Clinical manifestations (con..)
Wound botulism Without prodromal gastrointestinal disturbance Botulism has been reported after clostridial sinusitis after cocaine inhalation Incubation period is from 4 – 14 days B.Khodabakhshi
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Inhalation botulism Bioterrorism Non communicable
No obvious food source Multiple simultaneous outbreaks B.Khodabakhshi
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Differential diagnosis:
Myasthenia gravis Eaton lambert myasthenia syndrome(LEMS)no pupil involvement Tick paralysis Guillian- barre syn -sensory complaint -ascending -not alter pupil -areflexia Miller-fisher (ataxia) Poliomyelitis Magnesium intoxication Organophosphate poisoning Brain stem infarct Psychiatric illness B.Khodabakhshi
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Diagnosis: Hx is the important diagnostic test Diagnosis is clinical
Anaerobic culture and toxin assay -serum -stool -food Most sensitive toxin assay is mouse bioassay Elisa test and gel hydrolysis B.Khodabakhshi
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treatment: Elective intubation (decrease 30% vital capacity)
Purgatives Antitoxin ,1 vial im,1vial iv Human botulinum immune globulin 50mg/kg iv for infant botulism Antibiotic for wound botulism Antibiotic for infant botulism??? B.Khodabakhshi
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Prevention: Do not feed honey to children <1 yr of age
Proper food preservation methods Proper time, temperature and pressure 80oC for 30 min or 100oC for 10 min 85˚C for 5 min (NEW) Prompt refrigeration of foods Boil foods for > 10 minutes Decontamination Boil suspected food before discarding Boil or chlorine disinfect utensils used B.Khodabakhshi
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Any Question?? B.Khodabakhshi
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B.Khodabakhshi
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