Synonym: Clostridium botulinum infection;
Category: Biological Weapons
Agent Type: Toxin
Acuity: Acute-Severe
Latency/Incubation: Foodborne: 12 hours to 1.5 days or
longer; Inhalation: approximately 72 hours; [JAMA] Wound: 4-17 days;
Initial Symptoms: Ptosis and the 3 D's: Difficulty
seeing (Double vision), Difficulty swallowing, and Difficulty talking;
Precautions: Standard
Comments: EPIDEMIOLOGY: The four types of botulism are: wound, intestinal, foodborne, and inhalational. In the first two types, the toxin is produced by bacteria infecting the body. In the last two types, poisoning results from exposure to preformed toxin. Foods associated with botulism include home-canned vegetables and fruits in the USA and seal meat, smoked salmon, fermented salmon eggs, sausages, and seafood in other countries where sodium nitrate is less likely to be used as a meat preservative. Wound botulism has been reported in drug abusers related to dermal abscesses (heroin injection) and sinusitis (cocaine abuse). Honey may contain C. botulinum spores and is one of the causes of intestinal botulism in infants. FINDINGS: "Patients with botulism typically present with difficulty seeing, speaking, and/or swallowing." The impending paralysis may contribute to patient anxiety and hyperventilation. The classic triad of botulism is: 1.) bulbar palsies and descending paralysis; 2.) afebrile; and 3.) clear sensorium. Deep tendon reflexes are diminished or absent. In foodborne botulism, constipation, diarrhea, and/or vomiting may occur. In intestinal botulism, infants are weak, constipated, and "floppy" with loss of head control. Patients die from respiratory paralysis. Other symptoms after ingestion may include dry mouth, abdominal distention, urinary retention, postural hypotension, and paralysis of extraocular muscles. Symptoms progress over several days to respiratory paralysis. Less than 50% of patients have dilated or fixed pupils. Neurological deficits are symmetrical, and heart rate is normal. Respiratory distress results from airway obstruction due to a weakened glottis or from diaphragmatic paralysis. PREVENTION: The toxin is destroyed by cooking (heating >185 degrees F for at least 5 minutes). In the USA, the average number of foodborne outbreaks is 9 per year, and the average size is 2.5 patients per outbreak. Botulism antitoxin should be given as soon as the disease is suspected. Treatment should not be delayed while waiting for laboratory confirmation. There is a vaccine, but it has not been thoroughly tested.
[JAMA. 2001;285:1059-70; CCDM, p. 69-75;
5MCC-2006; PPID, p. 2824-5] The differential diagnosis of suspected botulism includes tick paralysis, myasthenia gravis, and the Miller-Fisher variant of Guillain-Barre syndrome. Patients may complain of dry mouth and sore throat.
[USAMRIID, p. 174] Patients present with ptosis and ophthalmoplegia with pupils that are dilated and poorly reactive to light and accommodation. Findings that distinguish botulism from myasthenia gravis: nausea/vomiting, poorly reactive pupils, and paralysis of accommodation. [Purvin V, Kawasaki A. Neuro-Ophthalmic Emergencies for the Neurologist. Neurologist. 2005 Jul;11(4):195-233.]
Diagnostic: Clinical; Detection of toxin in stool,
serum, food or other specimen;
Scope: Global
Signs & Symptoms: dizziness; fatigue;
pharyngitis; abdominal
pain; constipation; diarrhea; nausea, vomiting; deep tendon reflexes,
reduced; dysphagia; speech, impaired; weakness; vision, impaired; dyspnea,
acute; cyanosis, acute; cranial neuropathy; paralysis; peripheral neuropathy;
Common Syndromes: Acute GI Symptoms, No Fever; Acute
Neurological, No Fever;
Antimicrobic: Yes
Vaccine: Yes
Entry: Ingest, Inhale, Needle, Skin/Eye;
Source: Food, Edible Plant, Meat, Seafood-Fish, Soil;
High-Risk Activities: Eat undercooked meat or fish;
Ingest toxins in food or water; Work in a medical or research lab; Use
mood-altering drugs by injection;
Warfare: Victim--air release of chemicals/toxins;
Victim--water/food release
