History of Botulism

First discovered in 1793 as foodborne botulism by Justinus Kerner, a German physician. Associated with spoiled sausage and aptly named botulism after the Latin word for sausage, botulus. In 1897, Emile von Ermengen was able to correlate Clostridium botulinum to the disease.

Essential Facts about foodborne botulism

It is not an infection, but an intoxication. The toxin is produced by a specific bacterium. The toxin is ingested with the food and is not inactivate by the digestive processes. The organism is relatively resistant to mild chemical agents, but it is resistant to heat. The toxin is not produced if the concentration of NaCl is sufficiently high. Not all species of animals are susceptible.

Animals

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

Fairly resistant

No natural cases documented in cats

Epidemiology

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

Epidemiology

1977, Largest botulism outbreak

Michigan - 59 people Poorly preserved jalapeno peppers

Alaska
27% of U.S. foodborne botulism cases 1950-2000

226 cases from 114 outbreaks

Introduction to the Bacteria

Clostridium botulinum
straight to slightly curved, rod-shaped, motile by peritrichous flagella, and forms oval and subterminal spores, which usually swell the cell. Bacteria

Width: Length:

0.52.0 m 1.622.0 m

Occur naturally in soil, found in gastrointestinal tracts of animals as well as humans Survival is dependent on:

Water Anaerobic conditions

Neurotoxins

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

Neurotoxins
Neurotoxin
Human Horses Cattle

A
X

B
X X X

C
X X

E
X

F
X

X X X X

Sheep Dogs
Avian Mink & Ferret X

X X
X X

Distribution of spores in food and the environment

Type A and B are generally the cause of outbreaks in more temperate and warmer zones. Type A spores are found predominantly in soils. Type E is common in colder regions in the northern hemisphere and is mostly associated in fish and marine mammals.

Types C and D have been found in marshes inhabited by birds in localized areas around the world Type F is found soil. Type G is found in soil and is difficult to detect in mixed cultures

Four physiological groups

Group I- proteolytic types A, B and F Digest meat in cooked meat medium and casein in milk medium and liquefy gelatine in gelatine medium. They ferment glucose but not mannose or sucrose. Optimal temperature-35-40C, minimal temperature-10C Growth is inhibited by 10% NaCl

Group II- non proteolytic types B, F and all type E strains Do not digest casein or meat but they do liquefy gelatine Glucose is fermented, as are mannose and sucrose. Optimal temperature18-25C, minimal temperature-3.3C Growth is inhibited by 5% NaCl

Group III- types C and D Variably non-proteolytic or proteolytic. Gelatin is liquefied. Milk and meat are slowly digested. Glucose and mannose are fermented, while sucrose is not. Optimal temperature 40C, minimal temperature-15C Growth is inhibited by 3% NaCl Bacteriophage is involved in toxin production.

Group IV- type G Are proteolytic They slowly digest meat, while gelatine and meat are rapidly digested. Glucose, mannose and sucrose are not fermented. Optimal temperature 37C Growth is inhibited by 6.5% NaCl

Growth

Gram-positive
Anaerobic Temperature

Optimal: 40C Minimum:

Proteolytic: 10C Nonproteolytic: 3.3C

Minimum pH

Proteolytic: 4.6 Nonproteolytic: 5.0

Water Activity (aw): 0.94 (+NaCl controls growth) Redox Potential (E): -350 mV

Living Conditions

Limiting Factors

Low pH (acidic)

In the stomach, BoNTs occur in complexes with other proteins that protect it from acidity In the less acidic intestine, the complex disassociates and BoNT is then absorbed through the epithelial layer and enters the circulatory system

Nitrite, ascorbic acid, phenolic antioxidants, ascorbates Increase in calcium level counters the effects of BoNTs A and E

Botulism Pathogenesis

Incubation period ingestion: unknown foodborne: 6 hours-8 days wound: 4-14 days inhalation: (estimated) 24-36 hours Toxin enters bloodstream from mucosal surface or wound Binds to peripheral cholinergic nerve endings Inhibits release of acetylcholine, preventing muscles from contracting Symmetrical, descending paralysis occurs beginning with cranial nerves and progressing downward

Can result from airway obstruction or paralysis of respiratory muscles Secondary complications related to prolonged ventilatory support and intensive care

Human Botulism

3 Natural Forms:
Foodborne 2. Wound 3. Intestinal (infant and adult)
1.

Manmade Form: Inhalation Botulism

Foodborne Botulism

Preformed toxin ingested from contaminated food by C. botulinum. Spores that are present in the food germinate, reproduce and produce toxin in the anaerobic environment of the 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 Botulism

Most common form in U.S. Spore ingestion

Germinate then toxin released and colonize large intestine 94% < 6 months old Honey, food, dust, corn syrup

Infants < 1 year old

Spores from varied sources

Wound Botulism

Occurs when C. botulinum cells or spores alone or with other microorganisms infect a deep wound and produce toxin. 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 infectious botulism

In vivo multiplication of the organism and the subsequent production of toxin. occurs in wound botulism, but has also been seen when the multiplication results from colonization of the intestinal tract.

Adult 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 Signs

Constipation Lethargy Poor feeding Weak cry Bulbar palsies Failure to thrive

Botulism Transmission

Home-canned goods (foodborne) particularly low-acid foods such as asparagus, beets, and corn Honey (ingestion) can contain C. botulinum spores not recommended for infants <12 months old Crush injuries, injection drug use (wound)

Detection of C. botulinum

Enrichment Isolation Verification

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

Treatment

Intensive care immediately

Ventilator for respiratory failure

Botulinum antitoxin

Derived from equine source

Infant cases of types A and G

Botulism immune globulin

Human: 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

Botulism Infection Control

Botulism cannot be transmitted person-to-person

Standard precautions should be taken when caring for botulism patients

Botulism Laboratory Procedures

Toxin neutralization mouse bioassay serum, stool, gastric aspirate, suspect foods Isolation of C. botulinum or toxin feces, wound, tissue

Therapeutic use of the toxin

It was licensed as Oculinum to treat two eye conditions-blepharospasm and strabismus. Treat other medical conditions, such as:
Torticollis-contractions of the neck and shoulder muscles. Oromandibular dystonia-clenching of the jaw muscles. Spasmodic dysphonia-resultts in speech that is difficult to understand.

Why botulinum toxin has proved to be a good drug?

Toxin is highly selective in acting on cholinergic cells. Toxin has a long duration of action. Dose of toxin can be individually titrated for each patient to ensure maximal benefits

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