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| '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} | | '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} |
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| == Definition/Description == | | == Introduction == |
| | [[Image:Botulism 1.jpg|right|http://iamyouasheisme.wordpress.com/2010/02/10/botulism/|alt=|frameless]]Botulism is a neuroparalytic syndrome that results from the systemic effects of an exo neurotoxin produced by the spore-forming, anaerobic [[Bacterial Infections|bacterium]] Clostridium botulinum.<ref name=":0">Jeffery IA, Karim S. [https://www.statpearls.com/articlelibrary/viewarticle/18469/ Botulism.] StatPearls.Available:https://www.statpearls.com/articlelibrary/viewarticle/18469/ (accessed 19.12.2022)</ref> |
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| [[Image:Botulism 1.jpg|frame|right|http://iamyouasheisme.wordpress.com/2010/02/10/botulism/]]Botulism is a rare disease that can manifest through four naturally occurring patterns: food-borne botulism, wound botulism, infant botulism, and adult intestinal toxemia. There are also two forms of botulism that do not occur naturally, inhalation botulism and iatrogenic botulism. Botulism gets it's name from the organism that produces the associated symptoms, ''Clostridium botulinum. Clostridium botulinum'' produces seven distinct toxins which will all display a similar clinical pattern including symmetrical cranial nerve palsies which are followed by symmetric flaccidity of voluntary muscles. If allowed to progress long enough, the respiratory system could be affected leading to death.<sup><ref name="Sobel J">Sobel J. Botulism. Clin Infect Dis. (2005) 41(8): 1167-1173</ref> </sup> | | * Botulinum toxins are extremely lethal with the ability to block [[Neurone|nerve]] functions, potentially leading to respiratory and muscular paralysis. |
| | * Human classifications include: food borne botulism; infant botulism; wound botulism; inhalation botulism. |
| | * Food borne botulism often is caused by ingestion of home canned, preserved or fermented foodstuffs.<ref name=":1">World Health Organisation [https://www.who.int/news-room/fact-sheets/detail/botulism Botulism] Available:https://www.who.int/news-room/fact-sheets/detail/botulism (accessed 19.12.2022)</ref> |
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| | Watch this 3 minute video on Botulism- what it is and how it could kill you.{{#ev:youtube|v=rI9ysEaJzVs|300}}<ref>HTME. What is Botulism? Available from: https://www.youtube.com/watch?v=rI9ysEaJzVs [last accessed 19.12.2022]</ref> |
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| == Prevalence == | | == Etiology == |
| | Botulinum toxins are neurotoxic, affecting the [[Introduction to Neuroanatomy|nervous system]]. Botulinum neurotoxin is considered the deadliest toxin known due to its high potency and lethality, with a lethal dose of 1 ng to 3 nanograms of toxin per kilogram of body mass. The flaccid paralysis of botulism results from the irreversible inhibition of acetylcholine release at the presynaptic [[Axons|nerve termina]]<nowiki/>l of the neuromuscular junctions.<ref name=":0" /> |
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| '''Foodborne Botulism<sup><ref name="CDC">Center for Disease Control and Prevention. Botulism. Division of Bacterial and Mycotic Diseases. Online at http://www.cdc.gov/ncidod/dbmd/diseaseinfo/files/botulism_manual.htm. March 8, 2006.</ref></sup>:'''
| | Spores produced by the bacteria Clostridium botulinum (being heat-resistant and found widely in the environment) freely germinate, grow and then excrete toxins in anaerobic conditions..<ref name=":1" /> |
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| *Median number of foodborne botulism cases per year from 1990-2000 was 23 with a range of 17-43.
| | Transmission: There are three common forms of botulism. |
| *Most cases are sporadic involving only 2 or 3 people.
| | # Intestinal botulism (most common form). Caused by eating food, or swallowing dust or soil that contains the bacteria, Clostridium botulinum. Infants under the age of 12 months are most at risk and adults who have reduced gastrointestinal immunity. The bacteria multiply inside the gut and produce toxins. Healthy adults have natural defences in their gut that prevent the bacteria from multiplying usually. |
| *Alaska has the most cases per capita. This is due to the native style of food preparation.
| | # Food-borne botulism: Caused by eating food contaminated with toxins. Symptoms generally occur between 12 and 36 hours after eating the contaminated food. This form of botulism can be severe and may lead to death. |
| | # Wound botulism (rare form): Caused by bacteria (often in soil or gravel) entering the body through a wound or IV drug use. Symptoms can occur up to two weeks after the wound. |
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| [[Image:Food borne botulism map.jpg|Image:Food_borne_botulism_map.jpg]]
| | == Epidemiolgy == |
| | * In 2014, 123 cases of botulism were reported by 16 EU/EEA countries, including 91 cases reported as confirmed. Thirteen countries notified zero cases.<ref>ECDC [https://www.ecdc.europa.eu/en/publications-data/botulism-annual-epidemiological-report-2016-2014-data Botulism - Annual Epidemiological Report, 2016] [2014 data]. Available:https://www.ecdc.europa.eu/en/publications-data/botulism-annual-epidemiological-report-2016-2014-data (accessed 19.12.2022)</ref> |
| | * In Australia, there is typically only one case of botulism reported per year.<ref name=":2">Queensland Government [http://conditions.health.qld.gov.au/HealthCondition/condition/14/33/18/Botulism Botulism] Available:http://conditions.health.qld.gov.au/HealthCondition/condition/14/33/18/Botulism (accessed 19.12.2022)</ref> |
| | * In the United states, 5 years from 2011 through 2015, an average of 162 annual cases of botulism was reported.<ref name=":0" />''' ''' |
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| ''' [http://www.cdc.gov/ncidod/dbmd/diseaseinfo/files/botulism_manual.htm Foodborne Botulism Prevalence from 1950-1996]''' | | == 'Botox' == |
| | C. botulinum is the bacterium used to produce Botox, a product predominantly injected for clinical and cosmetic use (a purified and heavily diluted botulinum neurotoxin type A). <ref name=":1" />''' ''' |
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| <br>
| | == Characteristics/Clinical Presentation == |
| | Classic early botulism signs are cranial nerve palsies , progressing to the symmetrical descending weakness of the torso, limbs, and smooth muscle and eventual paralysis. Patients generally experience diplopia, dysphagia, dysphonia, and dysarthria. Diaphragm involvement triggers respiratory failure. |
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| '''Wound Botulism:'''
| | * Paralysis of autonomic smooth muscle leads to constipation and urinary retention. Those with food-borne botulism presenting often with a prodrome of abdominal pain, nausea, and vomiting beginning day 1 to day 3 after ingestion of toxin. |
| | * Infant Botulism has a variable presentation attributable to varying inoculum sizes, host vunerability, and time to presentation. Early symptoms involving constipation, weakness, feeding difficulties, weak cry, and drooling, potentially progressing to global hypotonia requiring immediate intubation and mechanical ventilation. |
| | * Wound botulism may present in people who present with cranial nerve symptoms and cellulitis following subcutaneous administration of illicit drugs, and presents with fever and infection signs. Wound botulism incubation takes 5 to 15 days from the time of spore introduction.<ref name=":0" /> |
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| *The incidence of wound botulism is 3 cases per year.<sup><ref name="Shapiro">Shapiro R, Hatheway C, Swerdlow D: Botulism in the United States: A clinical study and epidemiologic review. Annals of Internal Medicine. August 1998; 129: 221-228</ref></sup>
| | == Diagnosis == |
| *Wound Botulism is on the rise due to the increase of injection drug users specifically users of "[http://alcoholism.about.com/od/heroin/ig/heroin/black_tar.htm black tar heroin]" or "[http://alcoholism.about.com/od/slang/g/skin_popping.htm skin popping]"
| | Usually based on clinical history and clinical examination followed by laboratory confirmation including demonstrating the presence of botulinum toxin in serum, stool or food, or a culture of C. botulinum from stool, wound or food. |
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| <br> | | Differental diagnosis includes: [[Stroke]], [[Guillain-Barre Syndrome|Guillain-Barré syndrome]], or [[Myasthenia Gravis|myasthenia gravis]].<ref name=":1" /> |
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| '''Infant Botulism:'''
| | == Treatment == |
| | The only definite treatment for botulism is administrating antitoxin early, it being effective if given before botulism symptoms are obvious. Once symptoms appear, 75% of patients require long-term artificial ventilation for survival<ref>Atrium Health Wake Forest Baptist [https://medicalxpress.com/news/2022-07-drug-neuromuscular-weakness-counter-botulism.html New research shows drug used to treat neuromuscular weakness could counter botulism] JULY 25, 2022 Available:https://medicalxpress.com/news/2022-07-drug-neuromuscular-weakness-counter-botulism.html (accessed 23.12.2022)</ref>, with severe botulism cases needing supportive treatment, especially mechanical [[Ventilation and Weaning|ventilation]] (may be required for weeks or even months). [[Antibiotics]] are not required (excepting wound botulism). A botulism [[Vaccines|vaccine]] exists but it effectiveness has not been fully evaluated and it has harmful side effects.<ref name=":1" /> |
| | == Physical Therapy Management == |
| | Physical therapists will be a part of the supportive care team that is required for individuals with botulism. Their recovery will be dependent on the administering of the antitoxin as well as the help of the supporting staff to get the individual back to their normal selves. |
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| *Infant botulism is the most common form of botulism, accounting for 75% of the cases per year<sup><ref name="CDC" /></sup>. | | * [[Physiotherapists Role in ICU|Intensive Care]]: Close monitoring including frequent clinical evaluation of ventilation, perfusion, and upper airway integrity, continuous [[Pulse Oximeter|pulse oximetry]], [[spirometry]], and [[Arterial Blood Gases|arterial blood gas]] measurement. [[Ventilation and Weaning|Intubation]] is an option for patients with upper airway problems or vital capacity of less than 30% of predicted.<ref name=":0" /><br> |
| *The incidence of infant botulism is 71 cases per year.<sup></sup><ref name="Shapiro" />
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| *California has the most numerous cases of infant botulism. From 1976-1996 there were 680 reported cases in California while the second most 166 in Pennsylvania<ref name="CDC" />.
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| [[Image:Infant botulism map.jpg|http://www.cdc.gov/ncidod/dbmd/diseaseinfo/files/botulism_manual.htm]]
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| ''' [http://www.cdc.gov/ncidod/dbmd/diseaseinfo/files/botulism_manual.htm Infant Botulism Prevalence 1976-1996] '''
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| '''Other forms of Botulism:'''
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| *The prevalence of the other forms of botulism are very obscure and I was unable to find any specific numbers specifying how many cases there are per year.
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| == Characteristics/Clinical Presentation <sup><ref name="Sobel J" />,<ref name="Cox" />,<ref name="Goodman">Goodman C, Fuller K. Pathology: Implications for the Physical Therapist. 3rd ed. St. Louis: Saunders Elsevier; 2009</ref> </sup> ==
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| '''Initial Symptoms:''' All forms of botulism follow a similar clinical presentation. Food borne botulism symptoms develops 12-36 hours after ingestion of food containing the toxin<sup><ref name="Goodman" /></sup>
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| *The symptoms begin with cranial nerve palsies.
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| *Paralysis of the extra ocular muscles innervated through cranial nerves III (occulomotor), IV (trochlear), and VI (abducens).[[Image:BotulismPtosis.jpg|frame|right|Individual With Ptosis]] This causes blurry or double vision and the inability to accommodate near vision.
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| *Paralysis of cranial nerve VII (facial). This causes an expressionless face.
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| *Paralysis of cranial nerve IX (glossopharangeal). This can lead to regurgitation as well as dysphagia.
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| *Other early symptoms: dysarthria, a lack of sweating, severe dry mouth and throat, and finally postural hypotension.
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| *Food-borne botulism may initially present with nausea and vomiting. This is where it is very important to get an accurate eating history to rule out botulism. A stomachache, nausea, and vomiting for two days does not fit the initial presentation of the other forms.<sup></sup><ref name="Sobel J" /> ''' '''
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| '''Progressive symptoms<sup><ref name="Sobel J" /></sup>: '''Following the cranial nerve palsies, there may be a symmetric paralysis of voluntary muscles.
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| * Paralysis beginning at the muscles of the neck going down in to the shoulder girdles, and into the distal upper extremities.
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| *Paralysis will continue down into the lower extremities in roughly the same pattern.
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| *The diaphragm as well as other accessory breathing muscles may be affected which could lead to respiratory complications and possibly death.
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| *Due to the paralysis of voluntary musculature the patient may not show signs of agitation with respiratory arrest, such as gasping, thrashing, or flailing. Their death can arise from airway obstruction from pharyngeal muscle paralysis along with the paralysis of diaphragmatic and accessory respiratoy musculature.
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| *An almost universal symptom of progressing botulism is constipation. Deep tendon reflexes will diminish along with the corresponding paralysis levels.
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| *While the presentation is generally similar for all patients, the rate and degree of the paralysis between patient to patient varies proportional to the dose in which they were exposed.
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| <br>'''Other notes<sup><ref name="Sobel J" /></sup>:''' During the increasing stages of botulism some systems are left unharmed. There are no cognitive deficits involved. The patient will be able to communicate through either their difficult speech while intact or motions through fingers or toes as long as they are able to move still. At this point communication will be difficult if not impossible.<br><br>'''Infant botulism<sup><ref name="Sobel J" />,<ref name="Cox" /></sup>:''' The clinical presentation of botulism is the same with infants, however it may be harder to determine if the infant has blurry vision, dry mouth, or other initial symptoms.
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| *A table was developed by Schreiner MS, Field E, and Ruddy R. showing a review of 12 years' experience at the Children's[[Image:Infant botulism2.JPG|frame|Infant with extreme floppiness/weakness of his extremities]] Hospital of Philadelphia.
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| *Weakness or Floppiness is most common at 88% of infants.
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| *Poor Feeding occurs in 79% of infants.
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| *Constipation 65%
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| *Lethargy 60%
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| *Weak Cry 18%
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| *Irritability 18%
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| *Respiratory Difficulties 11%
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| *Seizures 2%.<sup><ref name="Cox">Cox N, Hinkle R. Infant Botulism. Am Fam Physician. 2002 Apr 1;65(7):1388-92</ref></sup>
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| == Associated Co-morbidities ==
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| *Botulism has no associated diseases and affects no one specific group more than another. While there are no associated co-morbidities, there are some risk factors for becoming infected with the botulinum toxin.
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| *'''Risk Factors''': injection drug users (primarily black tar heroin users and individuals who inject subcutaneously), infants under the age of one consuming honey, preparing your foods in ways that leave them susceptible for contamination, and any type of contact with botulinum toxin.'' ''
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| == Medications ==
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| '''Antitoxin therapy<ref name="Sobel J" />,<ref name="Cox" />:'''
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| *This is the only specific treatment for botulism.
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| *The antitoxin can stop the progression of paralysis and decrease the duration of paralysis and dependence on mechanical ventilation.
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| *Ideally should be given within 24 hours of onset of symptoms.
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| *In the past the treatment dose was 2-4 times more than it is at this time. Less than 1% of individuals have serious reactions.
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| *The prognosis is excellent for infants who received the human derived antitoxin. There is a case fatality rate of less than 2%.<ref name="Cox" />
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| *Recovery results from the regeneration of nerve terminals and motor endplates.<ref name="Cox" />
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| *There are two different types of antitoxin. The trivalent antitoxin is effective against three ''C. Botulinum ''neurotoxins, A, B, E. This version of the antitoxin is given by the CDC from quarantine stations. The heptavalent antitoxin is effective against seven neurotoxins, A, B, C, D, E, F, and G. This is only available through the Army or FEMA.<ref name="Mednet" />
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| '''Human Botulism Immune Globulin<ref name="Arnon">Arnon S, Schechter R, Maslanka S, Jewell N, Hatheway C. Human Botulism Immune Globulin for the Treatment of Infant BotulismThe New England Journal of Medicine. Boston: Feb 2, 2006. Vol. 354, Iss. 5; pg. 462, 10 pgs</ref>'''
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| *Treatment for Infant Botulism
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| *As compared with the control group in the randomized trial, infants treated with BIG-IV had a reduction in the mean length of the hospital stay, the primary efficacy outcome measure, from 5.7 weeks to 2.6 weeks
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| *No serious adverse effects
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| *In the open-label study, infants treated with BIG-IV within seven days of admission had a mean length of hospital stay of 2.2 weeks, and early treatment with BIG-IV shortened the mean length of stay significantly more than did later treatment
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| == Diagnostic Tests/Lab Tests/Lab Values ==
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| '''Primary Diagnostic Tool'''
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| *Confirmed with the "demonstration of the toxin in specimens of patient serum, gastric secretions, or stool or in a food sample." If the organism Clostridium botulinum is found in the patient's stool or in a wound (found through a culture) then a diagnosis of a botulism syndrome can be confidently used.
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| *This test is confirmed using a bioassay, which measures the amount of concentration in a sample.
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| *The test was standardized through the use of mice injected with the organism.
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| *For food botulism the samples taken for testing include: gastric secretions, vomitus, stool samples, as well as suspected foods. For wound botulism a sample of serum and anaerobic wound material is needed. For infant botulism, the preferred sample is a stool sample.
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| *The laboratory tests have had sensitivities reported as low as 33-44% but can vary with time of onset of symptoms. If a sample is taken more than one week after an ingestion of the organism the toxin may not be present in serum. However, it may be present in the patient's stool.<sup><ref name="Sobel J" /></sup>
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| '''EMG Evaluation of Suspected Cases of Infant Botulism<ref name="Cox" />'''
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| *Motor and sensory nerve conduction velocity in one arm and one leg
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| *Diagnostic triad for infant botulism: 1) Compound muscle action potentials of decreased amplitude in at least two muscle groups. 2) Tetanic and post-tetanic facilitation defined by an amplitude of more than 120 percent of baseline. 3) Prolonged post-tetanic facilitation of more than 120 seconds and absence of post-tetanic exhaustion.
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| *The EMG evaluation is used to assist in the primary tests mentioned above.
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| == Etiology/Causes ==
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| '''''Clostridium botulinum<ref name="Sobel J" />'''''
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| *A gram-positive bacteria that produces spores anaerobically.
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| *This bacteria is found globally in soil and aquatic sediments.<sup></sup><ref name="Who">World Health Organization. Online at: http://www.who.int/mediacentre/factsheets/fs270/en/. Revised August 2002</ref>
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| *Produces 7 immunologically distinct toxins designated by letters A-G.
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| *Human cases are caused mainly by A, B, and E.
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| *Produces botulinum toxins (Botox) that are large, single polypeptides that act on the cholinergic system. The toxins block acetylcholine at the presynaptic motor-neuron terminal causing flaccid paralysis. Botox is used both for its cosmetic and therapeutic benefits.
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| *Organism can survive standard cooking and food processing measures.
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| *Proper conditions for spore germination includes anaerobic milieu, nonacidic pH, low salt, and low sugar contents. Due to the conditions needed for germination the modern technique of canning foods was developed to kill the organism.
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| *Botulinum toxin is categorized as a category A biological agent. It has been used extensively as a weapon by governmental military programs as well as being deployed by a terrorist group.<sup></sup>
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| [http://www.youtube.com/watch?v=6n3rrjbweO8 {{#ev:youtube|6n3rrjbweO8}}]<br>
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| '''Different Causes of Botulism<ref name="Sobel J" />'''
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| '''1) Food Borne Botulism''': This is caused by the ingestion of foods contaminated with botulinum toxin. Home canned foods as well as a number of Alaska Native dishes (dishes that are fermented and consumed without cooking) are the main reasons for intoxication of individuals in the U.S.
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| '''[http://bioweb.uwlax.edu/bio203/s2008/strandwi_phil/new_page_1.htm][[Image:Wound botulism2.JPG|frame|left|Wound Botulsim]]2) Wound Botulism: '''This type is caused by the contamination of the wound with the organism's spores from the environment as well as the subsequent germination of the spores as well as production of the toxin in the perfect environment of an abscess. This type of botulism has been increasing in incidence since the early 1990's specifically due injection drug users. The injection drug associated individuals with botulism used a specific type of preparation of heroin. This was called "black tar heroin."As well as the different preparation, the patient injected the drug subcutaneously.
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| ''' '''
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| '''3) Infant Botulism:''' This results from ingested spores that germinate and colonize in the infant's GI tract, initially at the cecum. At this point the ileocecal valve might allow the colonizing bacteria to extend into the ileum. After colonization the toxin is produced and absorbed throughout the intestines. At this point the toxin begins it's block on the neruomuscular junctions inhibiting contractions.<sup><ref name="Cox" /></sup> The only identified food associated with infantile botulism is honey. It only accounts for a handful of the cases, but because of the correllation shown the FDA and CDC reccomends that you do not give honey to your chile under the age of one<ref name="Honey">Fenicia L, Ferrini AM, Aureli P, Pocecco M. A case of infant botulism associated with honey feeding in Italy. Eur. J. Epidemiol. November 1993. 671-673.</ref>.
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| '''4) Adult Intestinal Toxemia Botulism:''' Results from absorption of toxin produced by rarely occurring intestinal colonization in a few adults by botulinum toxin producing ''Clostridia''. This is also associated with anatomical or functional bowel abnormalities in the individual. This type of botulism is considered sporadic, meaning the symptoms come and go.<sup><ref name="Sobel J" /></sup>
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| '''5) Inhalational Botulism:''' This is one of the non naturally occurring types of botulism. Symptoms resemble food borne botulism. Deliberate spraying of this toxin could cause an outbreak of the disease.<sup></sup><ref name="Sobel J" />
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| '''6) Iatrogentic Botulism:''' Caused by the injection of botulinum toxin for cosmetic or medical treatments. Most of the time cosmetic doses are too low, but high doses are used for disorders such as cerebral palsy.<sup><ref name="Sobel J" /></sup>
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| == Systemic Involvement<ref name="Sobel J" /><ref name="Cox" /> ==
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| '''Cadiovascular:'''
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| *Most cases are accompanied by normal vital signs and blood pressure.
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| *The normal blood pressure is a result of a vagal blockade as well as extensive peripheral vasodilation which are both caused by the toxin.
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| *In some cases the individuals will present with hypotension.
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| '''Neuromuscular:'''
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| *Cranial nerve palsies mentioned above
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| *Paralysis starting from proximal to distal
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| *Progressive disappearance of deep tendon reflexes
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| *Loss of muscle tone
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| '''Gastrointestinal:<span id="fck_dom_range_temp_1302052697609_148" />'''
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| *Constipation almost always occurs in individuals with botulism
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| '''Urinary:'''
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| *Individual may have the inability to urinate
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| '''Respiratory:'''
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| *Paralysis of diaphragm and accessory breathing muscles possibly leading to respiratory arrest.
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| '''Central Nervous System:'''
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| *Infants occasionaly have seizures
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| == Medical Management (current best evidence) ==
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| '''Supportive Intensive Care<ref name="Sobel J" />,<ref name="Cox" />:'''
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| *Development of modern intensive care helped decrease the mortality rate among patients from 60-70% early in the 1900's to the current rate of 3-5%
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| *Patients diagnosed with botulism should be placed immediately in the ICU.
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| *Patient may need mechanical ventilation in a further progressed case.
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| *Frequent monitoring of vital capacity is also necessary
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| *Patient may need a nasogastric feeding tube
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| *Physical and Occupational Therapy while in supportive care
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| '''Antitoxin Therapy<ref name="Sobel J" />:'''
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| *The antitoxin is administered as soon as possible leading to a very promising rate of success
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| *The antitoxin can prevent the disorder from worsening but it still may take many weeks for a full recovery.<ref name="Mednet">MedicineNet. Available at: http://www.medicinenet.com/botulism/article.htm. Last Reviewed Dec 2009</ref>
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| *Side effects include anaphylaxis, hypersensitivity reactions, and serum sickness
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| '''Isolation and Infection Control<ref name="Sobel J" />:'''
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| *Standard precautions should be taken when evaluating and treating patients.
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| *While Botulinum Toxin cannot be absorbed through intact skin, it can be absorbed through the eye, mucosal surfaces, and non intact skin.
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| *Following a food history taken by the physician, it is necessary to contact the appropriate authorities
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| '''Surgical Intervention<ref name="Sobel J" />:'''
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| *Surgical debridement should be performed on a wound infected with the ''C. botulinum ''spores.
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| *Following the debridement, the wound should be cleaned and appropriate antimicrobial therapy should be provided.
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| == Physical Therapy Management (current best evidence)<ref name="patty">Gillette P. Cardiopulmonary: Breathing Exercises. Bellarmine University Physical Therapy Program. Fall 2010</ref> ==
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| Physical therapists will be a part of the supportive care team that is required for individuals with botulism. Their recovery will be dependent on the administering of the antitoxin as well as the help of the supporting staff to get the individual back to their normal selves. Some interventions are listed below, but the physical therapy management of a patient with botulism could be handled many different ways.
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| '''Breathing Exercises:'''
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| *Since respiratory failure is the primary cause for death in individuals with botulism it is very important to try to maintain controlled breathing as long as possible.
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| *Diaphragmatic controlled breathing will be important to try to maintain quality control of the respiratory cycle.
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| *Pursed lip breathing will be beneficial as well. The goal of this exercise will be to improve gas mixing at rest, decrease the mechanical disadvantage the individual might develop during the progression of botulism, and finally pursed lip breathing can reduce premature collapse of airways.
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| '''ROM Exercises:'''
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| *It is important for the patient to keep their joints moving as much as possible during their time in the hospital. ROM will begin as active until the patient loses function. The exercises will need to be continued passively if the individual has developed paralysis of the extremities.
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| '''Strengthening Exercises:'''
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| *Immobilization can do a lot of damage to the muscles of the body and it is the job of the physical therapist to keep the individual working on strengthening those muscles. In a patient with botulism it will be important to try to maintain the function as long as possible. While this is a progressive disease when the antitoxin is not administered, having the patient perform isometric exercises in their hospital bed can only help maintain that control and activation of the muscles until they finally fall to the toxin.
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| *Some exercises that would be effective include: Quad sets, Glut Sets, Short Arc Quads, Abduction at shoulders, bicep curls, etc.
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| *The hypotonicity associated with botulism needs the attention from the physical therapist from day one. The individuals will benefit from manual facilitation, verbal cueing, and numerous repetitions of motions. One would assume that a lot of the treatments would be similar to that of guillain barre syndrome. Both of these diseases can expect a good recovery when the appropriate measures are taken and physical therapy is a key ingredient to the patient's success.
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| '''Other Important Items:'''
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| *It is very important for the physical therapist to continue with communication to the patient in any way possible. In a progressed stage of botulism, communication may only be made through the movement of a single toe, but the patient will still be cognitively intact. It will be necessary to assess the patient's status before administering PT. This will not only help the therapist with thier treatments, they will be able to educate the individual and their family.<br>
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| == Differential Diagnosis<sup><ref name="Sobel J" /></sup> ==
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| *[http://www.ninds.nih.gov/disorders/gbs/gbs.htm Guillain-Barré Syndrome]
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| *[http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001731/ Myasthenia Gravis]
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| *Stroke Syndromes
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| *[http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001729/ Eaton-Lambert syndrome]
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| *Tick Paralysis
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| *[http://puffernet.tripod.com/tetrodotoxin.html Tetrodotoxin]
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| *[http://emedicine.medscape.com/article/818505-overview Shellfish Poisoning]
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| == Case Reports/ Case Studies ==
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| #Manfredi M, Scoditti U, Angelini M, de Giampaulis P, Borrini BM, Macaluso GM, Pavesi G, Vescovi P. Dry mouth as an initial sign of food borne botulism: a case report and review of the literature. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, And Endodontics. 2011 Apr; Vol. 111 (4), 15-18. Available at: <br>[http://ck8zf4yc8t.search.serialssolutions.com.libproxy.bellarmine.edu/?genre=article&isbn=&issn=1528395X&title=Oral+Surgery%2c+Oral+Medicine%2c+Oral+Pathology%2c+Oral+Radiology%2c+And+Endodontics&volume=111&issue=4&date=20110401&atitle=Dry+mouth+as+an+initial+sign+of+food-borne+botulism%3a+a+case+report+and+review+of+the+literature.&aulast=Manfredi+M&spage=e15&sid=EBSCO:MEDLINE&pid= http://ck8zf4yc8t.search.serialssolutions.com.libproxy.bellarmine.edu/?genre=article&isbn=&issn=1528395X&title=Oral+Surgery%2c+Oral+Medicine%2c+Oral+Pathology%2c+Oral+Radiology%2c+And+Endodontics&volume=111&issue=4&date=20110401&atitle=Dry+mouth+as+an+initial+sign+of+food-borne+botulism%3a+a+case+report+and+review+of+the+literature.&aulast=Manfredi+M&spage=e15&sid=EBSCO:MEDLINE&pid=]
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| #Pujar T, Spinello IM. Chest. A 38-year-old woman with heroin addiction, ptosis, respiratory failure, and proximal myopathy. 2008 Oct;134(4):867-70.Pujar T, Spinello IM. Available at: [http://www.ncbi.nlm.nih.gov/pubmed/18842921 http://www.ncbi.nlm.nih.gov/pubmed/18842921]
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| #Barash JR, Tang T, Arnon S. First case of infant botulism caused by ''Clostridium baratii ''type F in California. J Clin Microbiol. 2005 August; 43(8): 4280–4282. Available at: [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1233924/ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1233924/]
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| #Bhatia K, Münchau A, Thompson P, Houser M, Chauhan V, Hutchinson M, Shapira A, Marsden C. Generalised muscular weakness after botulinum toxin injections for dystonia: a report of three cases. J Neurol Neurosurg Psychiatry 1999;67:90–93. Available at: [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1736426/pdf/v067p00090.pdf http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1736426/pdf/v067p00090.pdf]
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| #Fenicia L, Ferrini AM, Aureli P, Pocecco M. A case of infant botulism associated with honey feeding in Italy. Eur. J. Epidemiol. November 1993. 671-673. Available at: [http://ck8zf4yc8t.scholar.serialssolutions.com/?sid=google&auinit=L&aulast=Fenicia&atitle=A+case+of+infant+botulism+associated+with+honey+feeding+in+Italy&id=doi:10.1007/BF00211445&title=European+journal+of+epidemiology&volume=9&issue=6&date=1993&spage=671&issn=0393-2990 http://ck8zf4yc8t.scholar.serialssolutions.com/?sid=google&auinit=L&aulast=Fenicia&atitle=A+case+of+infant+botulism+associated+with+honey+feeding+in+Italy&id=doi:10.1007/BF00211445&title=European+journal+of+epidemiology&volume=9&issue=6&date=1993&spage=671&issn=0393-2990]
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| == Resources <br> ==
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| #World Health Organization: [http://www.who.int/mediacentre/factsheets/fs270/en/ http://www.who.int/mediacentre/factsheets/fs270/en/]
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| #Center for Disease Control and Prevention: [http://www.cdc.gov/ncidod/dbmd/diseaseinfo/files/botulism_manual.htm http://www.cdc.gov/ncidod/dbmd/diseaseinfo/files/botulism_manual.htm]
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| #Journey to Perplexity: Botulism: [http://iamyouasheisme.wordpress.com/2010/02/10/botulism/ http://iamyouasheisme.wordpress.com/2010/02/10/botulism/]
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| #Phil Strandwitz: Botulism: [http://bioweb.uwlax.edu/bio203/s2008/strandwi_phil/new_page_1.htm http://bioweb.uwlax.edu/bio203/s2008/strandwi_phil/new_page_1.htm]
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| #Pub Med: [http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001624/ http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001624/]
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| == References == | | == References == |
