Chapter 134. Botulism (Part 4)

Botulism: TreatmentPatients should be hospitalized and monitored closely, both clinically and by spirometry, pulse oximetry, and measurement of arterial blood gases for incipient respiratory failure. Intubation and mechanical ventilation should bestrongly considered when the vital capacity is
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Chapter 134. Botulism (Part 4) Chapter 134. Botulism (Part 4) Botulism: Treatment Patients should be hospitalized and monitored closely, both clinically andby spirometry, pulse oximetry, and measurement of arterial blood gases forincipient respiratory failure. Intubation and mechanical ventilation should bestrongly considered when the vital capacity is cathartics and enemas may be used to purge the gut of toxin; emetics or gastriclavage can also be used if the time since ingestion is brief (only a few hours).Neither the use of antibiotics to eliminate an intestinal source of possiblecontinued toxin production nor the administration of guanidine hydrochloride andother drugs to reverse paralysis is of proven value. Treatment of infant botulism requires supportive care and administration ofhuman botulism immune globulin, which can be obtained by calling the CaliforniaDepartment of Health Services at 510-231-7600 or by following the instructions atwww.infantbotulism.org. Neither equine antitoxin nor antibiotics have been shownto be beneficial. In wound botulism, equine antitoxin is administered. The woundshould be thoroughly explored and debrided, and an antibiotic such as penicillinshould be given to eradicate C. botulinum from the site, even though the benefit ofthis therapy is unproven. Results of wound cultures should guide the use of otherantibiotics. Botulinum toxins are being employed for a variety of cosmetic andtherapeutic purposes, and new uses are being evaluated. Generalized botulism-likeweakness complicating therapy (iatrogenic botulism) has been reported but is rare. Prognosis Type A disease is generally more severe than type B, and mortality ratesfrom botulism are higher among patients above age 60 than among youngerpatients. With improved respiratory and intensive care, the case-fatality rate infood-borne illness has been reduced to ~7.5% and is low in infant botulism aswell. Artificial respiratory support may be required for months in severe cases.Some patients experience residual weakness and autonomic dysfunction for aslong as a year after disease onset. Prevention A pentavalent vaccine (types A through E) is available for use in highlyexposed individuals. Spores are highly resistant to heat but can be inactivated byexposure to high temperature (116–121°C) and pressure, as in steam sterilizers orpressure cookers used in accordance with the manufacturers instructions. Toxin isheat-labile and can be inactivated by exposure to a temperature of 85°C for 5 min.Newly identified cases should be reported immediately to public healthauthorities. Further Readings Arnon SS et al: Human botulism immune globulin for the treatment ofinfant botulism. N Engl J Med 354:462, 2006 [PMID: 16452558] ——— et al: Botulinum toxin as a biological weapon, in Bioterrorism:Guidelines for Medical and Public Health Management, DA Henderson et al(eds). Chicago, AMA Press, 2002, pp 141–165 Cawthorne A et al: Botulism and preserved green olives. Emerg Infect Dis11:781, 2005 [PMID: 15898180] Caya JG et al: Clostridium botulinum and the clinical laboratorian: Adetailed review of botulism, including biological warfare ramifications ofbotulinum toxin. Arch Pathol Lab Med 128:653, 2004 [PMID: 15163234] Centers for Disease Control and Prevention: Botulism from home-cannedbamboo shoots—Nan Province, Thailand. MMWR 55:389, 2006 Chertow DS et al: Botulism in 4 adults following cosmetic injections withan unlicensed highly concentrated botulinum preparation. JAMA 206:2476, 2006 Cooper JG et al: Clostridium botulinum: An increasing complication ofheroin misuse. Eur J Emerg Med 12:251, 2005 [PMID: 16175065] Gupta A et al: Adult botulism type F in the United States, 1981-2002.Neurology 65:1694, 2005 [PMID: 16344510] Lindström M, Korkeala H: Laboratory diagnostics of botulism. ClinMicrobiol Rev 19:298, 2006 Montecucco C, Molgo J: Botulinal neurotoxins: Revival of an old killer.Curr Opin Pharmacol 5:274, 2005 [PMID: 15907915] Sobel J: Botulism. Clin Infect Dis 41:1167, 2005 [PMID: 16163636] Bibliography Akbulut D et al: Improvement in laboratory diagnosis of wound botulismand tetanus among injecting illicit-drug users by use of real-time PCR assays forneurotoxin gene fragments. J Clin Microbiol 43:4342, 2005 [PMID: 16145075] Barr JR et al: Botulinum neurotoxin detection and differentiation by massspectrometry. Emerg Infect Dis 11:157, 2005 Centers for Disease Control and Prevention: Botulism in the United States,1899-1996: Handbook for epidemiologists, clinicians, and laboratory workers.Atlanta, CDC, 1998 (http://www.bt.cdc.gov/agent/botulism/) C ...