Botulism. Center for Food Security and Public Health Iowa State University 2004.

BotulismBotulism

Center for Food Security and Public Health Iowa State University 2004


OverviewOverview

• Organism• History• Epidemiology• Transmission• Disease in Humans• Disease in Animals• Prevention and Control


OrganismOrganism

• Clostridium botulinum−Gram positive−Obligate anaerobic bacillus−Spores

Ubiquitous Resistant to heat, light, drying and radiation Specific conditions for germination

• Anaerobic conditions• Warmth (10-50oC)• Mild alkalinity


NeurotoxinsNeurotoxins

• Seven different types: A through G−Different types affect different species−All cause flaccid paralysis −Only a few nanograms can cause illness−Binds neuromuscular junctions

• Toxin: Destroyed by boiling• Spores: Higher temperatures to be

inactivated


NeurotoxinsNeurotoxins

Neurotoxin A B C D E F G

Human X X X X

Horses X X

Cattle X X X

Sheep X

Dogs X X

Avian X X

Mink & Ferret X X X

TransmissionTransmission


TransmissionTransmission

• Ingestion−Organism−Spores−Neurotoxin

• Wound contamination• Inhalation• Person-to-person not documented

EpidemiologyEpidemiology


EpidemiologyEpidemiology

• In U.S., average 110 cases each year−Approximately 25% food-borne−Approximately 72% infant form−Remainder wound form

• Case-fatality rate−5-10%

• Infective dose- few nanograms

Disease in HumansDisease in Humans


Human DiseaseHuman Disease

• Three forms−Foodborne−Wound− Infant

• All forms fatal and a medical emergency

• Incubation period: 12-36 hours


Foodborne BotulismFoodborne Botulism

• Preformed toxin ingested from contaminated food

• Most common from home-canned foods −Asparagus, green beans, beets, corn,

baked potatoes, garlic, chile peppers, tomatoes; type A

− Improperly fermented fish (Alaska); type E


Infant BotulismInfant 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


Wound BotulismWound Botulism

• Organism enters wound−Develops under anaerobic conditions−From ground-in dirt or gravel− It does not penetrate intact skin−Associated with addicts of black-tar

heroin


Adult Clinical SignsAdult Clinical Signs

• Nausea, vomiting, diarrhea• Double vision• Difficulty speaking or swallowing• Descending weakness or paralysis

−Shoulders to arms to thighs to calves

• Symmetrical flaccid paralysis• Respiratory muscle paralysis


Infant Clinical SignsInfant Clinical Signs

• Constipation• Lethargy• Poor feeding• Weak cry• Bulbar palsies• Failure to thrive

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Selected Mimics that May Lead to Misdiagnosis of Botulism

Selected Mimics that May Lead to Misdiagnosis of Botulism

•

Condition Features Distinguishing Condition from BotulismCommon

• Guillain-Barré syndromea and its variants, especially Miller-Fisher variant History of antecedent infection; paresthesias; often ascending paralysis; early areflexia; eventual CSF protein increase; EMG findings Myasthenia gravisa Recurrent paralysis; EMG findings; sustained response to anticholinesterase Stroke aParalysis often asymmetric; abnormal CNS image Intoxication with depressants (e.g., acute alcohol intoxication), organophosphates, carbon monoxide, or nerve gas History of exposure; excessive drug levels detected in body fluids Lambert-Eaton syndrome Increased strength with sustained contraction; evidence of lung carcinoma; EMG findings similar to botulism Tick paralysis Paresthesias; ascending paralysis; tick attached to skin


Diagnosis Diagnosis

• Clinical signs• Toxin in serum, stool, gastric

aspirate, suspected food• Culture of stool or gastric aspirate

−Takes 5-7 days

• Electromyography also diagnostic• Mouse neutralization test

−Results in 48 hours


TreatmentTreatment

• Intensive care immediately−Ventilator for respiratory failure

• Botulinum antitoxin−Derived from equine source−CDC distributes−Used on a case-by-case basis

• Botulism immune globulin− Infant cases of types A and G

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TreatmentTreatment

• If diagnosed early, foodborne and wound botulism can be treated with an antitoxin which blocks the actions of toxin circulating in the blood. This prevents patients from worsening in condition.

• If respiratory failure and paralysis occur, the patient may be put on a breathing machine for weeks plus intensive medical and nursing care. Paralysis will improve after several weeks.

• Antitoxin is currently not routinely given for treatment of infant botulism.

Animals andBotulismAnimals andBotulism


AnimalsAnimals

• Cattle and sheep• Horses• Birds and poultry• Mink and ferrets• Uncommon in dogs and pigs

−Fairly resistant

• No natural cases documented in cats


Cattle and SheepCattle and Sheep

• Ingestion of toxin• Incubation

−24 hours to 7 days

• Sources−Spoiled stored silage or grain−Silage using poultry litter or products−Phosphorus deficiency in cattle−Carcasses: Baled or chopped into hay


Ruminants: Clinical SignsRuminants: Clinical Signs• Progressive ascending ataxia• Recumbent• Head turned into flanks • Cranial nerve dysfunction• Rumen stasis; bloat• Atonic bladder - loss of urination


Cattle and Sheep: DiagnosisCattle and Sheep: Diagnosis

• History• Bloodwork and CSF tap: Normal• ELISA test available for type C & D• Definitive diagnosis

−Demonstration of toxin in serum, gut contents or organs

• Electromyography (EMG)


Cattle and Sheep: TreatmentCattle and Sheep: Treatment

• Symptomatic and supportive• Nutritional• Ventilatory support, if needed• Metronidazole• Antitoxin, in early stages

− Ineffective by the time clinical signs are present

−Can block further uptake of toxin


HorsesHorses

• Horses, especially foals, are highly sensitive to botulism toxin

• Type B & C toxins• Incubation period

−24 hours to 7 days

• Sources−Contaminated feed−Wound infections


Adult HorsesAdult Horses

• “Forage poisoning”− Ingest preformed toxin

• Clinical Signs−Dyspnea−Flaccid tail−Muscle tremors−Severe paresis to rapid recumbency−Unable to retract tongue, drooling


FoalsFoals

• “Shaker Foal” syndrome−Most 2 weeks to 8 months old−On a high nutrition plane

• Spores in contaminated feed• Usually type B

−Most common in KY and eastern seaboard


Foals: Clinical SignsFoals: Clinical Signs

• Clinical signs−Paresis, recumbent−Muscle tremors−Dysphagia−Ptosis, mydriasis, decreased PLR− Ileus, constipation, urine retention−Death due to respiratory paralysis

• Mortality greater than 90%


Birds and PoultryBirds and Poultry

• “Limber neck”• Types C and E• Good sentinel species• Sources:

−Decomposed vegetation or invertebrates

− Ingest toxin or invertebrates with toxin−Contaminated feed or water of chickens


Birds and Poultry:Clinical Signs

Birds and Poultry:Clinical Signs

• Occurs 12-48 hours after ingestion• Droopy head• Drowsy• Wing and leg paralysis

−Unable to hold their head up−Unable to use their wings or legs

• Eyelid paralysis


Mink and FerretsMink and Ferrets

• Type C−Occasionally A and E

• Sources−Chopped raw meat or fish− Improper storage of meat by-products

• Vaccine available for type C


DogsDogs

• Rare• Type C; few cases type D• Source

− Ingestion of carrion−Wetland areas with avian botulism

epizootics

• Incubation period−Few hours to 6 days


DogsDogs

• Progressive symmetric ascending weakness−Rear limbs to forelimbs

• Cranial nerve deficits• Respiratory paralysis• Lose ability to urinate and defecate


DogsDogs

• Diagnosis−Bloodwork and CSF: Normal−Electromyography (EMG)−Toxin in serum, vomitus, feces, or

suspect food/carrion −Mouse neutralization test preferred

• Treatment−Supportive−Antitoxin

Prevention and ControlPrevention and Control


Human: PreventionHuman: 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

• Prompt refrigeration of foods• Boil foods for > 10 minutes• Decontamination

− Boil suspected food before discarding− Boil or chlorine disinfect utensils used


Ruminants: PreventionRuminants: Prevention

• Good husbandry practices• Rodent and vermin control• Prompt disposal of carcasses• Avoid spoiled feedstuff or poor

quality silage• Vaccination in endemic areas


Equine: PreventionEquine: Prevention

• Good husbandry• Rodent and vermin control• Avoid spoiled feed • Prophylactic vaccine for pregnant

mares−Currently only type B botulinum toxoid

available for horses


Potential Bioterrorism ThreatPotential Bioterrorism Threat

• Aum Shinriky cult• Extremely potent and lethal• Easily produced and transported• Signs of deliberate aerosol or

foodborne release of toxin−No common source −Large number of acute cases clustered−Uncommon toxin type (C, D, F, G)


Potential Bioterrorism ThreatPotential Bioterrorism Threat

• Point source aerosol release− Incapacitate or kill 10% of persons

within 0.5 km downwind

• CDC surveillance system−Prompt detection of botulism related

events


Additional ResourcesAdditional Resources

• CDC – Division of Bacterial and Mycotic Diseases− http://www.cdc.gov/ncidod/dbmd/

diseaseinfo/botulism_g.htm

• Center for Civilian Biodefense Strategies− http://www.hopkins-biodefense.org/pages/

agents/ agentbotox.html


AcknowledgmentsAcknowledgments

Development of this presentation was funded by a grant from the Centers for Disease Control and Prevention to the Center for Food Security and Public Health at Iowa State University.


AcknowledgmentsAcknowledgments

Author:

Co-author:

Reviewers:

Glenda Dvorak, DVM, MS, MPH

Radford Davis, DVM, MPH

Danelle Bickett-Weddle, DVM, MPHJean Gladon, BS

Botulism. Center for Food Security and Public Health Iowa State University 2004.

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