Updated: 6/1/2018

Clostridium botulinum

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Questions
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Snapshot
  • A 40-year-old man presents to the emergency room for blurry vision. He reports that the blurry and double vision started this morning along with nausea and vomiting. He also reports feeling weak in his arms. Upon further questioning, he recently ate a can of beans from his aunt in Alaska, where they run their own food storage business. On physical exam, there is bilateral ptosis and facial weakness. There is also bilateral upper arm weakness with absent deep tendon reflexes. His mental status is intact. His physician immediately administers antitoxin treatment for the disease.
Introduction
  • Classification
    • Clostridium botulinum
      • anaerobic gram + rod
      • produces botulinum exotoxin
    • transmission
      • ingestion of spore
      • ingestion of preformed toxins
      • direct wound contamination
      • inhalation (rare)
  • Epidemiology
    • demographics
      • adults
      • infants
    • risk factors
      • ingestion of old or expired bottles or cans of food or honey
      • wound contamination
      • intravenous drug use
  • Pathogenesis
    • forms spores
      • highly resistant to heat and chemicals
      • ingestion of spores causes infantile botulism
        • toxin is then produced in infant's gut
        • most commonly from ingestion of contaminated honey
    • forms heat-labile exotoxin
      • irreversibly inhibits acetylcholine release at the neuromuscular junction by cleaving SNARE proteins
      • ingestion of exotoxin causes adult botulism
    • botulinum toxin is absorbed into bloodstream from mucosal surface
    • botox injections are used for
      • focal dystonia
      • achalasia
      • muscle spasms
      • cosmetic appearance
  • Associated conditions
    • foodborne botulism
    • wound botulism
    • inhalation botulism
Presentation
  • Symptoms
    • gastrointestinal upset in foodborne botulism
    • infantile botulism
      • poor feeding and diminished suck
  • Physical exam
    • cranial nerve palsies
      • blurry vision
      • ptosis
      • facial weakness
      • drooping eyelids
      • 4 D’s
        • Diplopia
        • Dysarthria
        • Dysphagia
        • Dyspnea
    • autonomic nervous system dysfunction
      • dry mouth
      • postural hypotension
    • descending symmetric muscle weakness and flaccid paralysis
    • absent deep tendon reflexes
Studies
  • Labs
    • typically normal
    • toxin may be detected from serum, stool, or wound
      • process takes a few days, so this is only used as confirmatory testing
  • Making the diagnosis
    • most cases are clinically diagnosed
Differential
  • Guillain-Barré syndrome
    • distinguishing factor
      • typically an ascending paralysis
  • Bacterial meningitis in neonates
    • distinguishing factor
      • besides poor feeding or diminished suck, patients may have bulging fontanelle, nuchal rigidity, and abnormal labs
Treatment
  • Management approach
    • immediate treatment with antitoxin
  • Medical
    • equine-derived heptavalent antitoxin
      • indication
        • patients > 1 years of age
    • bivalent human-derived antitoxin (BabyBIG)
      • indication
        • patients < 1 years of age
Complications
  • Respiratory paralysis
  • Permanent paralysis
 

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Questions (3)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.MC.27) A 24-year-old college student consumed a container of canned vegetables for dinner. Fourteen hours later, he presents to the E.R. complaining of difficulty swallowing and double-vision. The bacterium leading to these symptoms is: Review Topic

QID: 101486
1

An obligate aerobe

11%

(30/283)

2

Gram-negative

10%

(29/283)

3

Rod-shaped

66%

(188/283)

4

Non-spore forming

3%

(9/283)

5

Cocci-shaped

9%

(25/283)

M1

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