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    Botulism – Diagnosis & Treatment

    Cardinal Presentations / Presenting Problems, Environmental Injuries / Exposures, Gastrointestinal, Infections, Neurological, Pediatrics, Respiratory, Toxicology

    Last Updated Dec 29, 2022
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    By Quentin Genuis, Tanis King

    First 5 Minutes

    • Prompt intubation for respiratory failure: intubation should be considered for patients with inadequate or worsening upper airway competency and those with a vital capacity <30% of predicted.(1)

    Context

    • Botulism is a rare, potentially fatal disease caused by the toxin produced by Clostridium botulinum spores – a bacteria found in soil and honey, and on fruits, vegetables, meats, and fish.(1)
    • Botulism spores are resistant to heat and thrive in moist, anaerobic environments. Improper canning of foods creates an ideal environment for botulism spores to grow and produce toxins.(2)
    • The main types of botulism include:(1,2,3)
      • Infant botulism: spores from C. botulinum enter the gastrointestinal tract and produce the toxin that causes illness in infants under 1 year of age.
      • Foodborne botulism: ingestion of food contaminated with botulinum toxin.
      • Wound botulism: spores from C. botulinum enter a wound and produce the toxin.
      • Iatrogenic botulism: high concentration of toxin is used for cosmetic or therapeutic procedures.

    Diagnostic Process

    • Diagnosis of botulism is made based on clinical findings of acute onset of cranial neuropathy and symmetric descending weakness, particularly in the absence of fever.
      • In infants, clinical illness is characterized by constipation, loss of appetite, weakness, altered cry, and ptosis.(1,2)
      • Foodborne botulism is characterized by blurred vision, dry mouth, and difficulty swallowing and speaking. Descending and symmetric paralysis may progress rapidly and may requires respiratory support.(1)
      • Wound botulism is characterized by diplopia, blurred vision, and bulbar weakness. Symmetric paralysis may progress rapidly.(1)
    • The decision to administer treatment is based on the clinical diagnosis of botulism and must not be delayed by laboratory confirmation of botulinum toxin in serum, stool, gastric aspirate, wound, or food or isolation of C. botulinum from stool, gastric aspirate, or wound.(5)

    Recommended Treatment

    • All patients with clinical findings suggestive of botulism should be hospitalized and monitored closely for signs of respiratory failure.
    • The treatment approach for all patients with botulism includes:
      • Administration of botulism antitoxin heptavalent (BAT) as soon as possible after diagnosing botulism.(1) Botulinum antitoxin binds to circulating botulinum toxins A to G to prevent the condition from getting worse but cannot reverse paralysis, thus, early administration is critical. When botulism is suspected, the attending physician must immediately contact the local Medical Health Officer (MHO) to coordinate access to antitoxin.(5)
      • Human-derived botulism immune globulin (BabyBIG®) is indicated in infant botulism caused by botulinum toxins A or B, rather than BAT.(2,5) The use of BabyBIG® must be approved through the Special Access Program, Health Canada (discussed further in related information).
      • Prompt intubation for respiratory failure: intubation should be considered for patients with inadequate or worsening upper airway competency and those with a vital capacity <30% of predicted.(1)
    • Antibiotics are not recommended for infant botulism or adults with suspected gastrointestinal botulism because they could increase the amount of toxin.(1,5)
    • Conduct frequent neurologic examinations with an emphasis on cranial nerve palsies, swallowing ability, respiratory status, and extremity strength throughout the patient’s course in the emergency department.(1)

    Criteria For Hospital Admission

    • All patients with clinical findings suggestive of botulism should be hospitalized and monitored closely for signs of respiratory failure.

    Criteria For Transfer To Another Facility

    • Dependent on local guidelines. In general, transfer may be considered if:
      • Patient care requirements exceed hospital capabilities (e.g., cardiac monitoring, intensive care, pediatric or maternal care, etc.)
      • Treatment is not available and cannot be delivered to current facility.
      • Specialist consultations are required and not available at current facility.
    • In British Columbia, any suspected case of botulism should be discussed with BCCH.

    Quality Of Evidence?

    Justification

    • Much of the evidence used for this clinical summary is derived from six systematic reviews that were in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. There is a wide range of studies included in the analyses with no major limitations.
    High

    Related Information

    OTHER RELEVANT INFORMATION

    1. BabyBIG®

      • BabyBIG® is not approved for use in Canada and is not stocked at BCCDC. The use of BabyBIG® in Canada must be approved through the Special Access Program, Health Canada. The treating physician must complete the Special Access Request Form A available here: http://www.hc-sc.gc.ca/dhp-mps/acces/drugs-drogues/index-eng.php
      • The form must be submitted by fax immediately (613) 941-3194. To avoid delays, all sections of the form must be completed accurately and it is recommended to follow-up with a phone call to the SAP office at (613) 941-2108 (24/7 line). If the case presents on a weeknight, weekend of holiday, the SAP on-call officer can be reached by telephone at this same telephone number (press 2). The treating physician should be prepared to provide the information required on the SAP Request Form to the on-call officer. Following administration of BabyBIG®, reporting of use must be submitted to

    Reference List

    1. Rao AK, Sobel J, Chatham-Stephens K, et al. Clinical Guidelines for Diagnosis and Treatment of Botulism, 2021. MMWR Recomm Rep 2021;70(No. RR-2):1–30. DOI: http://dx.doi.org/10.15585/mmwr.rr7002a1


    2. American Academy of Pediatrics Committee on Infectious Diseases. Botulism and infant botulism (Clostridium botulinum). In: Kimberlin DW, Brady MT, Jackson MA, editors. Red book. 31st ed. Itasca, IL: AAP; 2018. p. 283-286.


    3. Sobel J. Botulism. Clin Infect Dis. 2005;41(8):1167-1173. doi:10.1086/444507


    4. Leclair D, Fung J, Isaac-Renton JL, et al. Foodborne Botulism in Canada, 1985–2005. Emerg Infect Dis. 2013;19(6):961-968. https://doi.org/10.3201/eid1906.120873


    5. BC Centre for Disease Control. Communicable disease control manual. Botulism. Published November 2018. Accessed 22 November 2022. www.bccdc.ca/resource-gallery/Documents/Guidelines%20and%20Forms/Guidelines%20and%20Manuals/Epid/CD%20Manual/Chapter%201%20-%20CDC/Botulism_Guidelines.pdf.


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    RESOURCE AUTHOR(S)

    Dr Quentin Genuis

    Tanis King

    DISCLAIMER

    The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by Emergency Care BC (formerly the BC Emergency Medicine Network) and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. Emergency Care BC is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. Emergency Care BC also assumes no responsibility or liability for changes made to this document without its consent.

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