Botulism

 

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Original Editors - Elliot Mattingly from Bellarmine University's Pathophysiology of Complex Patient Problems project.

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Definition/Description

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 is 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. ¹

Prevalence

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Characteristics/Clinical Presentation

Initial Symptoms: All forms of botulism follow a similar clinical presentation.  The symptoms begin with cranial nerve palsies. The extra ocular muscles innervated through cranial nerves III (oculomotor nerve), IV (trochlear nerve), and VI (abducens nerve), are paralyzed causing blurry or double vision for the individual as well as the inability to accommodate near vision.  Along with the paralysis mentioned above, cranial nerves VII (facial nerve) and IX (glossopharangeal nerve) are also affected.  Facial nerve paralysis causes an expressionless face while the paralysis of the glossopharangeal nerve can lead to regurgitation as well as dysphagia. Some other prominent early symptoms include dysarthria, a lack of sweating, severe dry mouth and throat, and finally postural hypotension.¹  While all types of botulism have these symptoms, 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.

Progressive symptoms: Following the cranial nerve palsies, there may be a symmetric paralysis of voluntary muscles beginning at the muscles of the neck going down in to the shoulder girdles, and into the distal upper extremities.  It would continue down into the lower extremities in roughly the same pattern.  The diaphragm as well as other accessory breathing muscles may be affected which could lead to respiratory complications and possibly death.  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. An almost universal symptom of progressing botulism is constipation.  Deep tendon reflexes will diminish along with the corresponding paralysis levels.  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.

Other notes:  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.

Infant botulism:  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.  A table was developed by Schreiner MS, Field E, and Ruddy R. showing a review of 12 years' experience at the Children's Hospital of Philadelphia.  This table states that weakness or floppiness is the most common sign or symptom.  It occurs in 88% of the infants.  This is followed closely by poor feeding at 79%.  The rest include constipation 65%, lethargy 60%, weak cry 18%, irritability 18%, respiratory difficulties 11%, and seizures 2%.³

Associated Co-morbidities

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Medications

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Diagnostic Tests/Lab Tests/Lab Values

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Etiology/Causes

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Systemic Involvement

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Medical Management (current best evidence)

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Physical Therapy Management (current best evidence)

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Alternative/Holistic Management (current best evidence)

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Differential Diagnosis

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Case Reports/ Case Studies

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Resources

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Recent Related Research (from Pubmed)

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References

1) Sobel J. Botulism. Clin Infect Dis. (2005) 41(8): 1167-1173

2) Adanir T, Sencan A, Aksun M. A Food Borne Botulism May Cause Unnecessary Operation: A Case Report. Internet Journal of Emergency & Intensive Care Medicine. October 22, 2007;10(2):2

3) Cox N, Hinkle R. Infant Botulism. Am Fam Physician. 2002 Apr 1;65(7):1388-92.

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