1. Botulism Dr/ Mona M. Awny Assistant lecturer of forensic medicine & clinical toxicology

2. Food poisoning Most common bacterial food-borne pathogens: Clostridium botulinum Clostridium perfringens Escherichia coli Staphylococcus aureus Bacillus cereus Vibrio cholera

3. Clostridium botulinum ?? Gram +ve anaerobic bacillus that release neurotoxin “Botulin”.

5. Clostridium botulinum: Toxin types:  A / B / C alpha / C beta  D / E / F / G  Physical properties: - Spores withstand 100 c for hours. - Toxins are heat-labile and destroyed by boiling for 10 min. or heating at 80 c for 30 min.

6. Food sources Mainly not exposed to heat: 1. Salted fish “Fesikh” 2. Honey 3. Uncooked cold meat “Beef” 4. Home canned food

7. Botulism Fatal condition caused by ingestion of improperly preserved or canned food Types of Botulism Food related botulism: Classic botulism and Infant botulism Wound botulism

8. Dissemination of toxins Toxins are distributed to target sites via hematogenous dissemination

9. Toxins act on the presynaptic part of neuromuscular junctions leading to decreasing the amount of ACH release Mechanism of action “Neurotoxicity”

10. Clinical presentation Symptoms & signs develop within 12 – 36 hrs after ingestion Severity of disease depends on type of toxin (type A gives most severe picture) 1. GIT symptoms 2. Anticholinergic symptoms 3. Neurological symptoms

11. 1.Initial vague & GIT symptoms: Malaise, weakness, dizziness, diplopia & blurred vision Nausea, vomiting, diarrhea or constipation

12. 2.Anticholinergic manifestations:

13. Dry mucous membranes Markedly dilated pupils & blurred vision Urinary retention (palpable urinary bladder) Absent bowel sounds & abdominal distention No hyperthermia or tachycardia

14. 3.Neurological manifestations: Cranial nerve palsy Bilateral symmetrical descending flaccid paralysis of: 1. Bulbar musculature 2. Limbs 3. Resp. muscles & diaphragm No sensory loss Normal mental status

15. Cranial nerve palsy

17. Motor cortex Bulb/brainstem Bulbar musculature Eye movement M. of facial expression Speaking & swallowing

18. Symmetrical descending flaccid paralysis

19. Diaphragm

20. No sensory loss Normal mental status Death from respiratory failure

21. Investigations 1. General tests: ECG Abdominal U/S CSF Pulmonary function tests ABG

22. Investigations 2. Toxin-specific tests: C. botulinum toxin or spores in serum, stool, gastric contents or wound specimens Electromyography (EMG):  Shows a defect in transmission at the neuromuscular junction

23. Differential diagnosis Guillian-Barre syndrome:  Ascending paralysis, ↑CSF protein, normal EMG Cerebrovascular stroke:  Asymmetric Poliomyelitis:  Fever & meningeal signs Anticholinergic poisoning:  Fever & altered mental status

24. Management 1. General: ABC’s (early elective tracheostomy & mechanical ventilation) Emesis & gastric lavage Nasogastric suction (ileus) Foley catheterization (urine retention)

25. Management 2. Toxin-specific measures: Trivalent ABE antiserum Sensitivity test Dose: 1 vial IM & 1 vial IV A dose/ 4hrs if serum toxin persists

26. Follow-up & disposition Admission to ICU Monitoring of vital capacity & vital signs Prolonged hospitalization Slow recovery Rehabilitation program Complete recovery of paralysis takes up to 6 months

27. Wound botulism Soil Symptoms Wound swab Antitoxin, debridement, high- dose IV penicillin

28. Prevention