Botulism
Three types of Botulism
- Food (preformed toxin ingested) -- The main topic here
- Wound (organism grown in wound and forms toxin)
- Infantile (intestinal tract organism with formation of toxin)
Background
Botulism is very common here due to the fermented food that is considered a delicacy. Fish heads will be buried in the tundra for weeks and then dug up and eaten. If they were covered with Saran wrap or in a plastic container – they may be contaminated with botulism. Also seal oil that is sealed tightly is another risky food.
Botulism is a gram-positive anaerobic bacillus that can exist as a spore and resist killing. The toxin it releases interferes with neurotransmission at the peripheral cholinergic synapses preventing acetylcholine release. Fortunately, the toxin, which causes food poisoning, can be killed with boiling for 10 minutes or maintaining T+80c for 30 minutes.
Because lab tests for botulism take several days – the initial diagnosis depends on rapid clinical assessment. The incubation period is usually 12-36 hours.
Classic diagnostic pentad for botulism symptoms
- Diplopia -blurry vision – due to eye dilation,
- Dysphagia
- Dilated Fixed Pupils
- Dry Throat or mouth
- Nausea or Vomiting
The three major areas of clinical symptoms are gastrointestinal, neurological, and muscular:
- GI: Nausea/vomiting, ileus, diarrhea early, constipation late, and dry mouth.
- Neurologic: symptoms may follow the ingestion by 3 days and include dry mouth, blurry vision, diplopia, dilated or unreactive pupils, dysphagia, decreased gag reflex.
- Muscular: Symmetrical skeletal muscle weakness, respiratory muscle paralysis, fatigue, dyspnea
Botulism should be suspected in any patient with a history of consuming traditional fermented foods and symptoms such as weakness, dry mouth, blurred vision, urinary retention, ileus, diarrhea or dyspnea (especially without gasping or rapid respiratory rate.)
Possible contaminated foods need to be sent to the public health department in Anchorage. As soon as a case of botulism is suspected, the State Epidemiology Lab at 907-269-8000 or 800-478-0084, Public Health and YKHC’s Office of Environmental Health (OEH) need to be notified IMMEDIATELY. This is considered a public health emergency and therefore contacting people after hours and activating appropriate resources is essential.
Treatment
- Observation: the patients are followed with observation and Q 1 hour monitoring of their FVC.
- Equine produced antitoxin: will prevent further deterioration, but not resolve the symptoms. Because of our relatively high incidence of botulism here in the Yukon-Kuskokwim Delta region, we have several antitoxin kits available in the pharmacy and additional kits can be gold-streaked out from Anchorage from their stockpile if there is a large outbreak (many members of the same family ate the contaminated food, for example). There is a Botulism step-by-step protocol located in the ER as this is where most of the cases are sent once they are recognized. The protocol has very specific directions that accompany the antitoxin. Read them closely and consult with Anchorage CDC to see if it should be initiated. The instructions also include very specific directions for blood to be drawn PRIOR to administration of the antitoxin.
- Pre-emptive intubation and ventilation management should be considered if FVC falls to less than 80% of predicted or is diminishing over time in those with chronic lung disease. Please consult with an experienced provider when considering the management of botulism.
Resources/References
- Botulism in Alaska (pdf)
- State of Alaska website on botulism (a very nice booklet on botulism that outlines symptoms and case recognition and appropriate treatment)
- State of Alaska Epi Bulletins associated with Botulism
- Wound Botulism 2016 (PowerPoint Presentation)
- Botulism YKHC Clinical Guideline
