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Background: Botulism is a rare and life-threatening disease caused by the potent botulinum neurotoxin (BoNT), which can be produced by Clostridium botulinum (C. botulinum) and related bacteria. Clinical manifestations, which include a symmetrical, descending muscular paralysis, generalized hypotonia, and potentially respiratory failure, are non-specific and diagnosis is challenging, especially when anamnesis does not reveal any typical risk factor, like honey consumption. Case Presentation: We present what is, to the best of our knowledge, the first documented case of infant botulism (IB) in Sicily and discuss its peculiarities and the challenges faced in the diagnostic-therapeutic process. The infant was exclusively breastfed and no history of consumption of possibly contaminated foods, like honey, was found. The signs observed at presentation included poor suction, hypotonia, and hyporeactivity. A detailed anamnesis motivated the suspicion of botulism, due to the occurrence of constipation and exposure to dust from home renovation works during the days before the onset of symptoms. The botulinum antitoxin was administered and the diagnosis was confirmed through fecal examination, detecting toxin-producing C. botulinum. Conclusion: IB should be considered in every infant with rapidly progressing hypotonia and a history of constipation. However rarely, transmission could occur through inhalation of dust particles containing the toxin, therefore it is important to explore all possible sources of exposure. In the case described, timely diagnosis and treatment determined the successful outcome, which highlights the importance of early intervention in managing IB. [ABSTRACT FROM AUTHOR]

Infantile botulism is a potentially life-threatening neuromuscular disorder. It presents with descending paralysis that can involve the diaphragm and cause respiratory failure. Neurally adjusted ventilatory assist (NAVA) provides synchronized bilevel positive pressure by using electrical diaphragmatic (Edi) signals. Diaphragmatic paresis is thought to be a contraindication for using NAVA. However, the use of a NAVA catheter allows continuous assessment of diaphragm activity in infantile botulism. We discuss a case of infantile botulism in an infant from central Pennsylvania who presented with poor oral feeding, hypothermia, and lethargy and progressed to develop apnea and acute respiratory failure. The infant was intubated and mechanically ventilated. A diagnosis of infantile botulism was confirmed through the detection of botulinum toxin in the infant's stool, and the infant was treated with botulism immune globulin neutralizing antibodies. During his recovery phase, a NAVA catheter was placed, which allowed monitoring of Edi signals to gauge the return of diaphragm activity and to assist with the assessment of extubation readiness. We describe the trends in this infant's Edi signals following administration of globulin neutralizing antibodies and the successful transition to invasive, and subsequently, noninvasive NAVA. Our report demonstrates the clinical utility of monitoring diaphragmatic activity using a NAVA catheter and that NAVA provided adequate respiratory support to an infant during the recovery phase of infantile botulism. [ABSTRACT FROM AUTHOR]

A 41-year-old man developed rapidly progressive cranial neuropathies and muscle weakness followed by respiratory failure, requiring ventilation support. On examination, there was marked bilateral ptosis and ophthalmoplegia with bulbar, neck and proximal upper limb weakness. He had a recent open left humeral fracture that eventually required amputation. Despite immunoglobulin therapy, his progressive weakness continued. Multiple investigation results were inconclusive. Eventually, botulinum type A toxin was found positive, by which time the therapeutic window for antitoxin had passed. He continued on supportive management and was treated for concomitant infections and nosocomial illnesses. He was subsequently weaned from respiratory support and has made a good neurological recovery. [ABSTRACT FROM AUTHOR]

Audience: This oral board case is appropriate for emergency medicine residents and medical students (with senior resident assistance) on emergency medicine rotation. Introduction: Although a somewhat rare disease, infant botulism is a true pediatric emergency that carried a 90% rate of mortality prior to the development of an antitoxin.1 While botulism infections can be iatrogenic, foodborne, or involve infected wounds, infant botulism remains the most common presentation of this disease and accounts for approximately 70% of new cases annually.2 Caused by Clostridium botulinum, the inactive spores are ingested by the infant and germinate in the large intestine.3,4 The resulting neurotoxin prevents the release of acetylcholine at the presynaptic membrane which results in flaccid paralysis. Classically, the bulbar musculature is affected before somatic muscular, which results in the typical presentation of "descending paralysis."2,5 While confirmatory testing is important, it is often delayed by more than 24 hours, making both clinical recognition and implementation of treatment before confirmatory testing of vital importance.6,7 Treatment consists of providing airway, nutritional, and hydration support in addition to administering botulinum-specific antitoxin.8,9 While patients over the age of 12 months are treated with equine botulinum antitoxin, the Food and Drug Administration (FDA) has approved a human-derived immunoglobulin treatment, Botulism Immune Globulin Intravenous (BIG-IV, ie, "Baby BIG") for pediatric patients less than 12 months of age.1,2,6 Ordering BIG-IV is a complex and multidisciplinary process, requiring the treating physician to discuss any suspicious case with the Infant Botulism Treatment and Prevention Program (IBTPP) which is a branch of the California Department of Public Health.6 With early recognition and implementation of treatment, most infants will make a full recovery. Educational Objectives: At the end of this oral board session, examinees will: 1) demonstrate an ability to obtain a complete pediatric medical history, 2) perform an appropriate physical exam on a pediatric patient, 3) investigate a broad differential diagnosis for neuromuscular weakness in a pediatric patient, 4) recognize the classic presentation of infant botulism and implement treatment with botulinum specific antitoxin before confirmatory testing, 5) recognize impending airway failure and intubate the pediatric patient with appropriately dosed medications and ET tube size, and 6) demonstrate effective communication with healthcare team members and parents. Educational Methods: This oral board case followed the standard American Board of Emergency Medicinestyle case in a tertiary care hospital with access to all specialists and resources needed. This case was tested using 12 resident volunteers ranging from PGY 1-2 in an ACGME (Accreditation Council for Graduate Medical Education) accredited emergency medicine residency program. Learners were debriefed immediately after the case and were given the opportunity to provide feedback. Research Methods: The learners participating in the oral board case provided immediate feedback both by verbal discussion and via a written survey requiring them to rate the efficacy of the exercise. The efficacy of the educational content was assessed by comparing scoring measures of the ACGME core competencies across all learners based on post graduate year (PGY). Scoring measures were determined using a scale from 1-8, with 1-4 being unacceptable performance and 5-8 being acceptable. Efficacy required full completion of the oral board case by the residents as well as a debriefing session during which key educational concepts were discussed. Results: The practice oral board candidates consisted of 7 PGY1 and 5 PGY2 level residents. The average score of participating residents for each training level was PGY1: 4.5 and PGY2: 5.7. All except for 2 PGY2 residents missed at least one critical action with the majority of PGY1 residents missing more than one critical action for the case. All participating residents rated the educational value of the case as 4.75 (1-5 Likert scale, with 5 being excellent). Discussion: The educational content of this oral board case and debriefing session were effective for teaching the presentation, evaluation, and appropriate management of infant botulism. Infant botulism is a true pediatric emergency and prompt recognition and treatment is imperative in order to decrease mortality. While mortality was approximately 90% one hundred years ago, today infant botulism carries a much better prognosis due to the advent of antitoxin treatment with a mortality closer to 15%.1 This case highlights several classic physical exam findings including bulbar findings in addition to somatic weakness. Additionally, this case requires definitive airway management with endotracheal intubation, which is true for approximately 50% of infants with botulism.1 While a stool culture or direct toxin assay of the gastric contents, serum, or stool should be performed to confirm the diagnosis, these tests are often performed by the state health department or the Centers for Disease Control (CDC) and often take up to five days to result, during which time the patient will continue to deteriorate. Therefore, the treating physician should seek emergent consultation with the IBTPP to help facilitate the multidisciplinary decision to initiate treatment with human-derived anti-botulinum toxin antibodies.6 If the IBTPP deems that infant botulism is highly suspected based on the history and physical exam, then appropriate treatment should not be delayed and BIG-IV should be administered.6, 7 With early recognition and implementation of treatment, most infants will make a full recovery within several months to a year. Upon discharge, patients will likely require outpatient neurology follow-up in addition to physical therapy to aid in recovery. Because infant botulism is a true pediatric emergency with potentially high mortality, reaching the appropriate diagnosis expeditiously will allow the emergency physician to communicate effectively with worried parents regarding the disease progression and facilitate correct treatment early in order to prevent significant sequela. Topics: Pediatric weakness, pediatric neurotoxin, infant botulism, neuromuscular weakness. [ABSTRACT FROM AUTHOR]

Audience: This scenario was developed to educate emergency medicine residents on the diagnosis and management of wound botulism secondary to injection drug use. Introduction: Botulism is a relatively rare cause of respiratory failure and descending weakness in the United States, caused by prevention of presynaptic acetylcholine release at the neuromuscular junction. This presentation has several mimics, including myasthenia gravis and the Miller-Fisher variant of Guillain-Barré. It may be caused by ingestion of spores (infant), ingestion of pre-formed toxin (food-borne), formation of toxin in vivo (woundassociated cases), through weaponized sources, or through inappropriately administered injections (iatrogenic). Cases of black tar heroin injection have been associated with botulism. Regardless of the etiology, prompt assessment and support of respiratory muscle strength and ordering antidotal therapy is key to halting further muscle weakness progression. Educational Objectives: At the conclusion of the simulation session, learners will be able to: 1) Identify the different etiologies of botulism, including wound, food-borne, infant, iatrogenic, and inhalational sources, 2) describe the pathophysiology of botulism toxicity and how it prevents presynaptic acetylcholine release at the neuromuscular junction, 3) develop a differential for bilateral descending muscle weakness, 4) compare and contrast presentations of myasthenia gravis, botulism, and the Miller-Fisher variant of Guillain-Barré syndrome, 5) describe measurement of neurologic respiratory parameter testing, such as negative inspiratory force, 6) outline treatment principles of wound-associated botulism, including antitoxin administration, wound debridement, tetanus vaccination, and evaluation for the need of antibiotics, and 7) identify appropriate disposition of the patient to the medical intensive care unit (ICU). Educational Methods: This session was conducted using high-fidelity simulation, followed by a debriefing session and lecture on the diagnosis, differential diagnosis, and management of botulism secondary to injection drug use. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques. This scenario may also be run as an oral board case. Research Methods: Our residents are provided a survey at the completion of the debriefing session so they may rate different aspects of the simulation, as well as provide qualitative feedback on the scenario. Results: Sixteen learners completed a feedback form. This session received all six and seven scores (consistently effective/very good and extremely effective/outstanding, respectively) other than three isolated five scores. The form also includes an area for general feedback about the case at the end. Illustrative examples of feedback include: "Really awesome debrief, breakdown of pathophysiology and clinical applications. Great work!"; "Great case with awesome learning points," and "Loved this session. Rare case but very great learning." Specific scores are available upon request. Discussion: This is a cost-effective method for reviewing botulism diagnosis and management. The case may be modified for appropriate audiences, such as using classic illness scripting (eg, ingestion of canned foods). We encourage readers to utilize a standardized patient to demonstrate extraocular muscle weakness and bulbar symptoms to increase psychological buy-in. Topics: Medical simulation, botulism, toxicologic emergencies, toxicology, neurology, emergency medicine. [ABSTRACT FROM AUTHOR]

The article describes the case of an acute onset descending paralysis in a six-month-old male patient with pneumonia. Topics discussed include the patient's medical history, results of the patient's medical examinations, symptoms experienced by the patient, treatment given to the patient, and final diagnosis.

A 43-day-old, full-term, previously healthy male presented with decreased activity and oral intake. He was found to be grunting and hypoxemic on examination, and a respiratory pathogen panel was positive for rhinovirus. He was diagnosed with presumed bronchiolitis. His neurologic exam on admission was normal. Because of respiratory failure, he was escalated from high-flow nasal cannula to bilevel positive airway pressure upon admission and he was started on ceftriaxone and vancomycin while awaiting culture data. On hospital day 6, he required escalation of respiratory support. His examination at that time was notable for new hypotonia of his bilateral upper and lower extremities, sluggish pupils, bilateral exotropia, intermittent vertical nystagmus, and an absent Moro reflex. He developed a focal seizure and a computed tomography of the brain demonstrated simple right otomastoiditis. The seizure was attributed to a serum sodium of 113 mmol/L in the setting of syndrome of inappropriate antidiuretic hormone secretion, thought to be secondary to viral bronchiolitis. However, as the patient's sodiumwas corrected to a normal range, he continued to have neurologic deficits on examination. Given his persistent hypotonia and respiratory failure, atypical for the expected course of viral bronchiolitis, the patient underwent an extensive neurologic and infectious workup, which ultimately revealed a surprising diagnosis. [ABSTRACT FROM AUTHOR]

Botulism is a neuro-paralytic syndrome caused by the production of a neurotoxic protein by Clostridium botulinum. It is a rare but potentially fatal poisoning. Symptoms are due to blockage of neurotransmitter release at the neuromuscular junction. Botulism usually occurs following ingestion, inhalation or contact of the toxin with a wound. More recently, cases of iatrogenic botulism have been described, notably following the injection of toxin for therapeutic or cosmetic purposes. In spring 2023, an outbreak of iatrogenic botulism following intragastric injections was reported in Europe. Here, we provide an overview of botulism, followed by a presentation of the only two Swiss cases reported during the epidemic., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Background: Botulism has not been previously reported in the Kingdom of Saudi Arabia. This rare and sometimes fatal foodborne illness is caused by neurotoxins and primarily results from consuming home-canned fruits, vegetables, dairy, and seafood products & it can lead to paralysis., Objective: The purpose of this study was to evaluate the clinical features of patients who developed botulism in Riyadh in 2024 after consuming mayonnaise from a well-known local chain of restaurants in Riyadh, Saudi Arabia., Methods: We conducted a retrospective analysis of medical records and interviewed patients or their attendants for all hospitalized cases of foodborne botulism at Riyadh First Health Cluster. For each patient, a standard case report form was completed, containing information on demographics, clinical aspects, botulinum test results, and type of exposure. Descriptive statistics were applied to assess the data. During the outbreak, nineteen patients with foodborne diseases were admitted to Riyadh First Health Cluster Hospitals. Following thorough physical examinations, botulism was suspected in each case., Results: Eight of the 19 suspected foodborne illness patients fully satisfied the botulism case definition requirements set forth by the Saudi Arabian Public Health Authority (Weqaya). Among these eight patients, 2 (25%) were male and 6 (75%) were female, with a mean age of 23.25 ± 9.29 years (range: 12-38 years). The incubation period for our patients was 36.25 ± 26.26 h. Notable symptoms included dysphagia in all eight patients (100%), dysarthria, generalized weakness, nausea and vomiting in seven patients (88%), diplopia in four patients (50%), and stomach discomfort in three patients (38%). Of the eight cases, six required intubation, one mimicked brain death, and two were stable. The presence of Clostridium botulinum spores as the cause of the outbreak was confirmed by detecting botulinum spores in contaminated food., Conclusion: Diplopia and dysarthria were the most common early sign of botulism. Early manifestations may include respiratory symptoms without any musculoskeletal symptoms. or nausea, vomiting and disorientation., (© 2024. The Author(s).)

Animal welfare and ethical considerations limit the use of the mouse lethality bioassay for the detection of botulinum toxins. This study assessed an ELISA and RT-PCRs to detect toxin types C and D in samples from mammals with flaccid paralysis or weakness. DNA/RNA tightly bound to the toxin molecules were used as surrogates for the presence of toxin. In total 391 diverse samples from 101 clinical cases from cattle and 9 other species were examined. Botulism was confirmed by ELISA in samples from 16 cases. Toxin type C or D was identified by RT-PCR in 10 cases, five of which were among the cases confirmed by ELISA. Among the 80 cases with negative samples, sampling was not comprehensive enough in 66 cases (botulism therefore not excluded) but was adequate in 14 cases (no indication of botulism). The last two categories included 16 cases with other laboratory findings explaining the clinical signs. The ELISA that detects botulinum C and D toxins was superior in identifying cases with positive samples compared to the RT-PCRs but the latter were able to identify the toxin type present when positive. Furthermore, the RT-PCRs are available to any laboratory with molecular testing capability. Both laboratory assays can screen a comprehensive range and a large number of samples which is crucial for a successful diagnosis of botulism., (© 2024. Crown.)

Introduction: Botulism is a serious condition that carries with it a high rate of morbidity and mortality., Objective: This review highlights the pearls and pitfalls of botulism, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence., Discussion: Botulism is a neuromuscular disorder caused by toxin production of clostridium species bacteria and is a challenging diagnosis that mimics several other conditions. Children account for the majority of patients, with a foodborne source most common, followed by wound sources, typically from intravenous drug injection. Classically, patients with botulism develop bilateral cranial nerve palsies and symmetric, bilateral, descending paralysis. However, patients may initially present with vague symptomatology, such as weakness and dry mouth, which can make diagnosis challenging. A careful history elucidating exposures such as intravenous drug use or consumption of non-commercial canned products can help differentiate botulism from other disorders causing neuromuscular weakness. If suspected, the Centers for Disease Control should be notified to mobilize antitoxin for treatment as soon as the diagnosis is suspected even prior to confirmatory testing. Antibiotics should be avoided in these patients, as they can potentiate toxin release, unless there is a concomitant infection requiring antibiotic therapy. Patients with botulism can develop respiratory compromise requiring emergent airway management. Prolonged neuromuscular blockade from botulism will lead to a variety of symptoms that require comprehensive intensive care unit level care., Conclusion: An understanding of botulism and its many potential mimics can assist emergency clinicians in diagnosing and managing this deadly disease., Competing Interests: Declaration of competing interest None. None of the authors have submitted a review on this topic or published previously on this topic. No AI program was utilized in the construction of this manuscript., (Published by Elsevier Inc.)

Botulinum neurotoxin serotype A (BoNT-A) has several therapeutic indications such as spasticity and dystonia. Although its use is generally considered safe, a systemic diffusion can lead to systemic complications, and a botulism-like syndrome can occur after intramuscular injections. Herein, two adult cases who developed general muscle weakness after a BoNT-A intramuscular injection are reported. Both presented with a progressive decrement on low-frequency (LF) repetitive nerve stimulation (RNS). It is suggested that a progressive decrement on LF-RNS in muscles distant from the injection site strongly supports the diagnosis of iatrogenic botulism., Competing Interests: Declaration of competing interest The authors report no competing interests., (Copyright © 2024 The Authors. Published by Elsevier Masson SAS.. All rights reserved.)

Botulism is a paralytic disease due to the inhibition of acetylcholine exocytosis at the neuromuscular junction, which can be lethal if left untreated. Botulinum neurotoxins (BoNTs) are produced by some spore-forming Clostridium bacteria. The current confirmatory assay to test for BoNTs in clinical specimens is the gold-standard mouse bioassay. However, an Endopep-MS assay method has been developed to detect BoNTs in clinical samples using benchtop mass spectrometric detection. This work demonstrates the validation of the Endopep-MS method for clinical specimens with the intent of method distribution in public health laboratories. The Endopep-MS assay was validated by assessing the sensitivity, robustness, selectivity, specificity, and reproducibility. The limit of detection was found to be equivalent to or more sensitive than the mouse bioassay. Specificity studies determined no cross-reactivity between the different serotypes and no false positives from an exclusivity panel of culture supernatants of enteric disease organisms and non-toxigenic strains of Clostridium . Inter-serotype specificity testing with 19 BoNT subtypes was 100% concordant with the expected results, accurately determining the presence of the correct serotype and the absence of incorrect serotypes. Additionally, a panel of potential interfering substances was used to test selectivity. Finally, clinical studies included clinical specimen stability and reproducibility, which was found to be 99.9% from a multicenter evaluation study. The multicenter validation study also included a clinical validation study, which yielded a 99.4% correct determination rate. Use of the Endopep-MS method will improve the capacity and response time for laboratory confirmation of botulism in public health laboratories., Competing Interests: The authors declare no conflict of interest.

Objectives: To shed some light on a potential therapeutic modality that may facilitate resolution of botulism symptoms, namely 3,4-diaminopyridine (3,4-DAP)., Methods: In Riyadh, Saudi Arabia, we recently encountered a foodborne botulism outbreak that, luckily, was discovered early. In Prince Sultan Military Medical city, we admitted, during a period of approximately 3 weeks, 15 probable cases, 2 of which were excluded due to more likely alternative diagnoses. We report in this case series 13 highly suspected cases of botulism that we encountered during the outbreak., Results: A total of 12 out of 13 patients required intensive care unit (ICU) admission, one of which required intubation. Symptoms included cranial nerve palsies, gastrointestinal symptoms, limb and respiratory muscle weakness. Patients showed clinical improvement when received botulinum antitoxin and 3,4-DAP if given early in the course of the disease., Conclusion: Early admisntration of 3,4-DAP may facilitate recovery and prevent disease progression. Larger prospective trials should be carried out to confirm that., (Copyright: © Saudi Medical Journal.)

Background: Clostridium botulinum remains a major threat to a select population of subcutaneous and intramuscular drug users. We conducted a retrospective study of patients who were diagnosed with wound botulism and their clinical presentations to the Emergency Department (ED). Results: A total of 21 patients met the inclusion criteria and all had a confirmed history of heroin use disorder. Initial presentation to the ED included generalized weakness (n = 20, 95%), difficulty swallowing (n = 15, 71%), and speech/voice problems (n = 14, 79%). Sixteen patients (76%) also presented with visible skin wounds and fifteen (71%) required mechanical ventilation (MV). Patients who presented with dysphagia as well as dysarthria and/or dysphonia were more likely to require a percutaneous endoscopic gastrostomy (PEG) tube. Patients who required MV and PEG tubes were noted to have a longer hospital length of stay (LOS) due to the severity of the disease progression. Conclusions: Emergency physicians should remain vigilant about early recognition of wound botulism, especially in patients who inject drugs. [ABSTRACT FROM AUTHOR]

Published information about fish botulism is scant. We review here the current literature on fish botulism. Freshwater fish are susceptible to botulism. Only anecdotal evidence exists about possible botulism cases in saltwater fish. With only a few exceptions, the etiology of all cases of fish botulism reported is Clostridium botulinum type E, although fish are sensitive to, and may carry, various C. botulinum types. Clinical signs of botulism in fish include loss of equilibrium and motion, abducted opercula, open mouths, dark pigmentation, and head up/tail down orientation in which attempts to swim result in breaching the surface of the water. Dark pigmentation is thought to be associated with acetylcholine imbalance in botulinum neurotoxin (BoNT)-affected fish. Rarely, but similar to the situation in other animal species, fish can recover from botulism. Fish botulism can cause secondary outbreaks of the disease in birds, as botulism-affected fish stand out from normal fish, and are selectively preyed upon by fish-eating birds, which thus become intoxicated by the BoNT present in sick fish. The source of BoNT in fish has not been definitively confirmed. Fish may ingest C. botulinum spores that then germinate in their digestive tract, but the possibility that fish ingest preformed BoNT from the environment (e.g., dead fish, shellfish, insects) cannot be ruled out. The presumptive diagnosis of botulism in fish is established based on clinical signs, and as in other species, confirmation should be based on detection of BoNT in intestinal content, liver, and/or serum of affected fish., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

In the fall of 2021, a significant mortality event in free-ranging Southern Lapwing (Vanellus chilensis) occurred on a soccer field in southern Brazil. Approximately 130 adult southern lapwings died after showing weakness and flaccid paralysis, characterized by the inability to move or fly and drooped wings. Due to the large number of animals affected, there was concern that they had been criminally poisoned. The affected birds were found to have ingested maggots in fresh poultry litter incorporated into the grass surface. Postmortem examinations of four southern lapwings revealed no significant gross and histological findings. Polymerase Chain Reaction (PCR) for influenza A virus, flavivirus, and paramyxovirus was negative. Based on the epidemiological and clinical findings and the negative viral results, a presumptive diagnosis of botulism was made. This diagnosis was confirmed through mouse bioassay and seroneutralization, which detected botulinum toxin type C. Maggots loaded with botulinum neurotoxins were the probable vehicle for intoxication in the outbreak. Considering the impact of avian botulism on wild bird populations, our results may help prevent similar outbreaks in the future., (© 2023. The Author(s), under exclusive licence to Springer Nature B.V.)

Introduction: Iatrogenic botulism is a rare, serious disease that progresses with descending paralysis and develops after cosmetic or therapeutic botulinum toxin-A (BoNT-A) application., Case Presentations: In this case series; six cases of iatrogenic botulism followed up in our center are presented. Four of these developed after gastric BoNT-A and two after axillary BoNT-A application., Results: The most important cause for the disease was the use of unlicensed products and high-dose toxin applications. The first symptoms were blurred vision, double vision, difficulty in swallowing, and hoarseness. Symptoms appeared within 4-10 days after the application of BoNT-A. Symptoms progressed in the course of descending paralysis in the following days with fatigue, weakness in extremities and respiratory distress. Diagnosis was based on patient history and clinical findings. The main principles of foodborne botulism therapy were applied in the treatment of iatrogenic botulism. If clinical worsening continued, regardless of the time elapsed after BoNT-A application, the use of botulinum antitoxin made a significant contribution to clinical improvement and was recommended., Conclusions: Routine and new indications for BoNT-A usage are increasing and, as a result, cases of iatrogenic botulism will be encountered more frequently. Physicians should be alert for iatrogenic botulism in the follow-up after BoNT-A applications and in the differential diagnosis of neurological diseases that are presented with similar findings., Competing Interests: No Conflict of Interest is declared, (Copyright (c) 2024 Fatma Eser, İmran Hasanoğlu, Bircan Kayaaslan, Ayşe Kaya Kalem, Şule Bilen, Gürdal Orhan, Rahmet Güner.)

Objective: To summarize the clinical characteristics and prognosis of severe infant botulism and evaluate the therapeutic effect of botulinum antitoxin in the pediatric intensive care unit (PICU). Methods: The clinical data of 8 cases diagnosed with infantile botulism were retrospectively analyzed in the PICU of Beijing Children's Hospital from October 2019 to August 2023. Data of basic demographic information, clinical manifestations, laboratory tests, treatment and prognosis of each child were collected and analyzed using descriptive statistical methods. Results: Eight laboratory-confirmed cases of infant botulism were included in this study, all of which were male infants with an age of 6.0 (3.3,6.8) months. Three of the children were from Inner Mongolia Autonomous Region, 2 of them were from Hebei, and the other 3 were from Beijing, Shandong and Xinjiang Uyghur Autonomous Region, respectively. All the patients were previously healthy. In 4 of these cases, the possible cause was the ingestion of either honey and its products or sealed pickled food by the mother or child before the onset of the disease. The first symptom was poor milk intake (4 cases), followed by shallow shortness of breath (7 cases), limb weakness (7 cases) and so on. The typical signs were bilateral dilated pupils (8 cases) and decreased limb muscle strength (8 cases). The main subtype was type B (7 cases), and only 1 case was classified as type A. Six of the children were treated with antitoxin therapy for a duration of 24 (19, 49) d. Seven of them had invasive mechanical ventilation. All the patients survived upon discharge with a follow-up period of 29 d to 3 years and 8 months. Six patients had fully recovered, and 2 recently discharged patients were gradually recovering. Conclusions: For infants with suspected contact or ingestion of botulinum and presented with bilateral pupillary paralysis, muscle weakness and clear consciousness, the stool should be collected for diagnostic testing using a mouse bioassay as soon as possible. Type B was the most common type. The antitoxin treatment was effectiveness and the prognosis was well.

This case study describes severe iatrogenic botulism following treatment with a botulinum toxin injection at a private clinic abroad.

A 42-year-old man, returning to Europe after a 2-month stay in China, reported cough and runny nose. Five days later, he developed neck discomfort and rapidly evolving weakness, spreading from his arms to the facial, bulbar and neck muscles, and then the legs. He developed dysphagia and breathlessness, and was intubated in the emergency department. Cerebrospinal fluid showed mildly elevated protein. On day 2 he had fixed dilated pupils, with absent oculocephalic reflexes, and a flaccid upper limb paralysis. MR scans of the brain and spinal cord were normal. The early features of descending weakness, bulbar involvement and fixed dilated pupils made it difficult to distinguish between Guillain-Barré syndrome and botulism, and early investigations were inconclusive. We initially gave both botulinum antitoxin and intravenous immunoglobulin, but initially delayed plasma exchange as this would have removed the botulinum antitoxin. Diagnostic testing for botulism has low sensitivity, so we urge preemptive treatment if it is clinically suspected. [ABSTRACT FROM AUTHOR]

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• Botulism is a form of paralysis caused by a neurotoxin from the bacterium Clostridium botulinum ; wound botulism rarely occurs. • We present a very rare case of wound botulism in an infant, possibly associated with the application of medical-grade honey. • In this case there was a high association of honey consumption and botulism; the importance of honey in topical wound care is questionable. • We review the dilemma regarding the difficulty of confirmation and achieving the diagnosis. Botulism is a form of paralysis caused by a neurotoxin produced by the bacterium Clostridium botulinum. It is well known that natural honey contains Clostridium botulinum spores; controversy arises when a honey-related product is being used for wound care, where the possibility occurs of applying these spores to an open wound. To our knowledge, no reported cases of medical-grade honey have been associated with wound botulism. Given this fact, do we feel secure regarding the safety of this product, and will it be enough to alleviate our concern? We present a case of an infant with an infected umbilical stump, which required a surgical wound debridement. This infant developed a sudden progressive flaccid paralysis a few days after the application of topical medical grade honey for wound care. Even though suspicion of wound botulism is high, confirmation of the diagnosis, detection of neurotoxin, and isolating the organism remains a challenge. [ABSTRACT FROM AUTHOR]

Objectives: Botulism is a rare syndrome characterized by acute, flaccid paralysis with possible involvement of respiratory muscle-producing pump failure requiring mechanical ventilation. A predominance of autonomic involvement can occur., Methods: We enrolled patients affected by foodborne botulism during an outbreak. All patients underwent the detection of the toxin in stool specimens, and 24-hour ambulatory blood pressure monitoring (ABPM). A blinded expert operator analyzed ABPM data for the diagnosis of hypertension and postprandial hypotension (PPH)., Results: Twenty male patients met the inclusion and exclusion criteria. Thirty-four healthy subjects matched for sex and age were enrolled as a control group. PPH was significantly more frequent in the botulin group than in healthy subjects (40% vs 2.9%, P <0.0001). At the logistic regression, the probability that patients affected by botulinum could require ventilation was increased by 733% (adjusted odds ratio: 8.33) when PPH is encountered., Conclusions: The likelihood of resorting to ventilation in subjects with botulinum intoxication was seven times greater in patients presenting PPH. These results could allow the prompt identification of patients at high risk for requiring ventilation., Competing Interests: Declaration of competing interests All authors declare that they have no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

In September 2023, a severe outbreak of type B botulism with fifteen cases was linked to consumption of canned sardines at a restaurant in Bordeaux, France, during the Rugby World Cup. The cases were from seven countries. One death was recorded. Outbreak investigation using credit card data, rapid communication between health authorities of the affected countries and broad media communication allowed identification of cases and exposed persons and prevented further severe outcomes.

Background: Clostridium botulinum is an anaerobic, Gram-positive, rod-shaped bacterium that forms spores and the neurotoxin botulinum. It is best known for its toxin-induced flaccid paralytic disease, which is deadly without correct treatment. In this report, we show a completely different clinical course with fatal outcome., Case Presentation: A 37-year-old African man born in Sierra Leone was admitted. After admission, his condition rapidly worsened due to severe septic shock and progressive multiorgan failure. No neurological signs were seen. Despite treatment with antibiotics, fluid resuscitation, and norepinephrine, the multiorgan failure deteriorated further and he died as a result. Blood and synovial fluid cultures showed Clostridium botulinum. No botulinum toxins were found., Conclusion: This is a rare case of fatal septic shock due to Clostridium botulinum-induced septic arthritis without any sign of the classic clinical syndrome of botulism., (© 2023. BioMed Central Ltd., part of Springer Nature.)

During 2006-2021, Canada had 55 laboratory-confirmed outbreaks of foodborne botulism, involving 67 cases. The mean annual incidence was 0.01 case/100,000 population. Foodborne botulism in Indigenous communities accounted for 46% of all cases, which is down from 85% of all cases during 1990-2005. Among all cases, 52% were caused by botulinum neurotoxin type E, but types A (24%), B (16%), F (3%), and AB (1%) also occurred; 3% were caused by undetermined serotypes. Four outbreaks resulted from commercial products, including a 2006 international outbreak caused by carrot juice. Hospital data indicated that 78% of patients were transferred to special care units and 70% required mechanical ventilation; 7 deaths were reported. Botulinum neurotoxin type A was associated with much longer hospital stays and more time spent in special care than types B or E. Foodborne botulism often is misdiagnosed. Increased clinician awareness can improve diagnosis, which can aid epidemiologic investigations and patient treatment.

Infantile botulism is an uncommon diagnosis and rarer still in the neonatal period. We describe three cases of neonatal-onset botulism that presented with symptoms typically (hypotonia, constipation, facial diplegia) or atypically seen in older infants (encephalopathy, seizures, and hypothermia). Our series shows a wider spectrum of clinical presentations in patients with neonatal-onset botulism. Our report also suggests that neonatal-onset botulism should be considered more broadly in the hypotonic infant, especially as the condition is treatable with intravenous botulinum-specific immune globulin., Competing Interests: Declaration of Competing Interest The authors declare no potential conflicts of interest with respect to the authorship and/or publication of this article., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Botulism is an uncommon severe neuromuscular disorder. We report two recent cases of confirmed infant botulism diagnosed in an 11-week and a 5-month-old infant along with electroneuromyogram (ENMG) findings. Then, we discuss the EMG features of infant botulism. In severe forms of infant botulism, presence of these features might help decide to use botulinum immune globulin. To our knowledge, case 1 is the first case reported in France based on confirmed dust contamination. [ABSTRACT FROM AUTHOR]

The aim of this study is to assess the neurophysiological abnormalities of type A botulin toxin-infiltrated human muscle, and their evolution over time. Seried cMAP measurements, 3 and 20 Hz repetitive nerve stimulation, EMG, SFEMG over 3 months from toxin injection. Our findings consist in lack of decrement with 3 Hz repetitive nerve stimulation and facilitation with 20 Hz repetitive nerve stimulation; progressive increasing of jitter; early appearance of fibrillations; small and short motor unit action potential in the first 3 weeks, followed by increasing of MUAP amplitude and duration, with polyphasic morphology. Although claimed as highly specific and sensible, neuromuscular junction facilitation is an inconstant finding in human botulism. Therefore, lack of neuromuscular junction facilitation cannot exclude a diagnosis of botulism. Our findings are compatible with a process of acute denervation followed by distal reinnervation, favored by terminal nerve sprouting. [ABSTRACT FROM AUTHOR]

We describe a rare presentation of botulism originally presenting with exclusively unilateral cranial nerve deficits following a puncture wound to the face. Cephalic tetanus was initially suspected but laboratory testing confirmed botulism. Botulism caused by local diffusion of toxin from a contaminated head wound can be confused with cephalic tetanus. [ABSTRACT FROM AUTHOR]

Background. Botulism is a rare, sometimes lethal neuroparalytic illness. On 2 October 2011, an inmate at prison A developed symptoms compatible with botulism after drinking pruno, an illicit, prison-brewed alcoholic beverage. Additional illnesses were identified within several days. We conducted an investigation to determine the cause and extent of the outbreak. Methods. A case was defined as signs or symptoms of botulism in a prison A inmate with onset during 30 September-9 October 2011. Cases were identified through medical evaluations and interviews with inmates about recent pruno consumption. Laboratory testing was performed for Clostridium botulinum and botulinum neurotoxin. Ingredients, preparation, and sharing of the implicated pruno were investigated. Results. Eight prisoners developed botulism; all drank pruno made with a potato. Three received mechanical ventilation. Culture of fluid from a sock that inmates reported using to filter the implicated pruno yielded C. botulinum type A. The implicated batch may have been shared between cells during delivery of meal trays. Challenges of the investigation included identifying affected inmates, overcoming inaccuracies in histories, and determining how the illicit beverage was shared. Costs to taxpayers were nearly $500 000 in hospital costs alone. Conclusions. Pruno made with potato has emerged as an important cause of botulism in the United States. This public health response illustrates the difficulties of investigating botulism in correctional facilities and lessons learned for future investigations. [ABSTRACT FROM AUTHOR]

Background. Botulism is classically described as a bilateral, symmetric, descending flaccid paralysis in an afebrile and alert patient without sensory findings. We describe the reported spectrum of clinical findings among persons >12 months of age in the United States during 2002-2015. Methods. The Centers for Disease Control and Prevention collects clinical findings reported by physicians treating suspected cases of botulism nationwide. We analyzed symptoms and signs, and neuroimaging and cerebrospinal fluid (CSF) results. A case was defined as illness compatible with botulism with laboratory confirmation or epidemiologic link to a confirmed case, and presence or absence of at least 1 sign or symptom recorded. Physicians' differential diagnoses were evaluated. Results. Clinical information was evaluated for 332 botulism cases; data quality and completeness were variable. Most had no fever (99%), descending paralysis (93%), no mental status change (91%), at least 1 ocular weakness finding (84%), and neuroimaging without acute changes (82%). Some had paresthesias (17%), elevated CSF protein level (13%), and other features sometimes considered indicative of alternative diagnoses. Five of 71 (7%) cases with sufficient information were reported to have atypical findings (eg, at least 1 cranial nerve finding that was unilateral or ascending paralysis). Illnesses on the physician differential included Guillain- Barré syndrome (99 cases) and myasthenia gravis (76 cases) and, rarely, gastrointestinal-related illness (5 cases), multiple sclerosis (3 cases), sepsis (3 cases), and Lyme disease (2 cases). Conclusions. Our analysis illustrates that classic symptoms and signs were common among patients with botulism but that features considered atypical were reported by some physicians. Diagnosis can be challenging, as illustrated by the broad range of illnesses on physician differentials. [ABSTRACT FROM AUTHOR]

Background. Botulism is a rare, potentially severe illness, often fatal if not appropriately treated. Data on treatment are sparse. We systematically evaluated the literature on botulinum antitoxin and other treatments. Methods. We conducted a systematic literature review of published articles in PubMed via Medline, Web of Science, Embase, Ovid, and Cumulative Index to Nursing and Allied Health Literature, and included all studies that reported on the clinical course and treatment for foodborne botulism. Articles were reviewed by 2 independent reviewers and independently abstracted for treatment type and toxin exposure. We conducted a meta-analysis on the effect of timing of antitoxin administration, antitoxin type, and toxin exposure type. Results. We identified 235 articles that met the inclusion criteria, published between 1923 and 2016. Study quality was variable. Few (27%) case series reported sufficient data for inclusion in meta-analysis. Reduced mortality was associated with any antitoxin treatment (odds ratio [OR], 0.16; 95% confidence interval [CI], .09-.30) and antitoxin treatment within 48 hours of illness onset (OR, 0.12; 95% CI, .03-.41). Data did not allow assessment of critical care impact, including ventilator support, on survival. Therapeutic agents other than antitoxin offered no clear benefit. Patient characteristics did not predict poor outcomes. We did not identify an interval beyond which antitoxin was not beneficial. Conclusions. Published studies on botulism treatment are relatively sparse and of low quality. Timely administration of antitoxin reduces mortality; despite appropriate treatment with antitoxin, some patients suffer respiratory failure. Prompt antitoxin administration and meticulous intensive care are essential for optimal outcome. [ABSTRACT FROM AUTHOR]

Effective treatment for botulism requires early clinical recognition. Diagnosis of botulism, including during outbreaks, can be challenging. We assessed combinations of signs and symptoms among confirmed cases and identified sensitive clinical criteria to trigger suspicion. We produced a tool that may facilitate rapid identification of sporadic and outbreak-associated cases. [ABSTRACT FROM AUTHOR]

Background. Maternal and fetal outcomes associated with botulism and botulinum antitoxin use during pregnancy and the postpartum period have not been systematically reviewed. Methods. We searched Global Health, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Scopus, and Medline databases from inception to May 2015 for studies published on botulism or botulinum antitoxin use during pregnancy and the postpartum period, as well as the Centers for Disease Control and Prevention National Botulism Surveillance database. Our search identified 4517 citations. Results. Sixteen cases of botulism during pregnancy (11 in the third trimester) and 1 case during the postpartum period were identified. Ten cases were associated with confirmed or likely foodborne exposure; 2 cases were attributed to wound contamination related to heroin use, and the source of 5 cases was unknown. Eleven women with botulism had progressive neurologic deterioration and respiratory failure, requiring intensive care unit admission. Four women had adverse outcomes, including 2 deaths and 2 women who remained in a persistent vegetative state. No neonatal losses or cases of congenital botulism were reported. Among the 12 cases that reported neonatal data, 6 neonates were born preterm. No adverse maternal or neonatal events were identified as associated with botulinum antitoxin therapy among 11 patients who received it. Conclusions. Our review of 17 cases of botulism in pregnant/postpartum women found that more than half required ventilator support, 2 women died, and 6 infants were born prematurely. A high level of clinical suspicion is key for early diagnosis and treatment of botulism. Care of pregnant women or new mothers with botulism can include preparation for possible intubation. [ABSTRACT FROM AUTHOR]

Background. Botulism manifests with cranial nerve palsies and flaccid paralysis in children and adults. Botulism must be rapidly identified and treated; however, clinical presentation and treatment outcomes of noninfant botulism in children are not well described. Methods. We searched 12 databases for peer-reviewed and non-peer-reviewed reports with primary data on botulism in children (persons <18 years of age) or botulinum antitoxin administration to children. Reports underwent title and abstract screening and full text review. For each case, patient demographic, clinical, and outcome data were abstracted. Results. Of 7065 reports identified, 184 met inclusion criteria and described 360 pediatric botulism cases (79% confirmed, 21% probable) that occurred during 1929-2015 in 34 countries. Fifty-three percent were male; age ranged from 4 months to 17 years (median, 10 years). The most commonly reported signs and symptoms were dysphagia (53%), dysarthria (39%), and generalized weakness (37%). Inpatient length of stay ranged from 1 to 425 days (median, 24 days); 14% of cases required intensive care unit admission; 25% reported mechanical ventilation. Eighty-three (23%) children died. Median interval from illness onset to death was 1 day (range, 0-260 days). Among patients who received antitoxin (n = 193), 23 (12%) reported an adverse event, including rash, fever, serum sickness, and anaphylaxis. Relative risk of death among patients treated with antitoxin compared with patients not treated with antitoxin was 0.24 (95% confidence interval, .14-.40; P < .0001). Conclusions. Dysphagia and dysarthria were the most commonly reported cranial nerve symptoms in children with botulism; generalized weakness was described more than paralysis. Children who received antitoxin had better survival; serious adverse events were rare. Most deaths occurred early in the clinical course; therefore, botulism in children should be identified and treated rapidly. [ABSTRACT FROM AUTHOR]

Background. Botulism is a rare, potentially fatal paralytic illness caused by neurotoxins. To inform the evaluation of patients with suspected botulism, we conducted a systematic review to describe the clinical features of botulism. Methods. We searched Medline Ovid, Embase Dialog, Embase Ovid, Cumulative Index to Nursing and Allied Health Literature (CINAHL) EBSCO, Global Health Ovid, Cochrane Library, Scopus, and ClinicalTrials.gov for English language articles through May 2015. Information abstracted included demographics, signs and symptoms, laboratory results, and clinical outcome for foodborne and wound botulism patients confirmed by laboratory testing, epidemiologic link, or association with an outbreak. The review followed PRISMA guidelines and was registered with PROSPERO (CRD42015024784). Results. We identified 402 patients from 233 articles published in English between 1932 and 2015. Most cases (n = 346 [86%]) were foodborne botulism and most (n = 263 [65%]) were associated with an outbreak. The median incubation period was 1 day, and the median time from illness onset to hospital admission was 2 days. Shortness of breath, dyspnea, or respiratory distress or failure at hospital admission was reported in 169 (42%) patients; 71 (42%) reported respiratory involvement without report of extremity weakness. Among 154 patients for whom the hospital day of intubation was reported, 134 (87%) were intubated on the first or second hospital day. Conclusions. Botulism patients can experience a range of signs and symptoms. Respiratory involvement may occur early in the illness and can occur without preceding extremity weakness. Clinicians and public health departments preparing for and responding to botulism events should use this information to guide the evaluation of suspected botulism patients. [ABSTRACT FROM AUTHOR]

Laboratory-based pathogen isolation, identification, and toxicity determination were performed on samples from a suspected case of infant botulism. Mice injected with cultures generated from the enema sample and ingested Powered infant formula (PIF) presented typical signs of botulism. Antitoxins to polyvalent botulinum neurotoxins (BoNTs) and monovalent BoNT type B antitoxin had protective effects. Clostridium botulinum isolated from the enema and residual PIF samples were positive for type B toxin. Pulsed-field gel electrophoresis (PFGE) revealed that the two strains of C. botulinum isolated from the two samples produced indistinguishable pulsotypes. These findings confirmed this case of type B infant botulism associated with the ingestion of PIF contaminated by type B C. botulinum spores. [ABSTRACT FROM AUTHOR]

Botulism is a severe and potentially lethal paralytic disease caused by several botulinum neurotoxin-producing Clostridia spp. In China, the majority of the cases caused by botulism were from less-developed rural areas. Here, we designed specific substrate peptides and reconfigured gold nanoparticle-based lateral flow test strip (LFTS) to develop an endopeptidase-based lateral flow assay for the diagnosis of botulism. We performed this lateral flow assay on botulinum neurotoxin-spiked human serum samples. The as-prepared LFTS had excellent performance in the detection of botulinum neurotoxin using only 1 μL of simulated serum, and its sensitivity and specificity were comparable to that of mouse lethality assay. Moreover, the assay takes only half a day and does not require highly trained laboratory staff, specialized facility, or equipment. Finally, our LFTS can be potentially extended to other serotypes of BoNTs by designing specific substrate peptides against the different types of BoNTs. Overall, we demonstrate a strategy by which LFTS and endopeptidase activity assays can be integrated to achieve facile and economic diagnosis of botulism in resource-limited settings. [ABSTRACT FROM AUTHOR]

Botulism is one of the most important foodborne diseases and is caused by Clostridium botulinum toxin. The main manifestations are flaccid muscle paralysis and cranial nerve palsies. Botulism is an essential health problem because of its high mortality. The diagnosis of botulism, especially in sporadic cases, is a medical challenge and a high clinical suspicion is necessary for early recognition. So, every physician should be familiar with its signs and symptoms for early detection and treatment. We describe a family with dysphasia and acute paralysis after the ingestion of locally made cheese. The clinical presentations of the 1st patient were similar to myasthenic crisis and she, therefore, received plasma exchange. After the appearance of similar symptoms in the other family members, they were treated with polyvalent botulinum antitoxin and diagnosis was confirmed by toxicology and detection of serotype A botulinum toxin in cheese and stool samples. Uncommon clinical presentations and unusual sources of botulinum toxin should be kept in mind because of the importance of early diagnosis and treatment. [ABSTRACT FROM AUTHOR]

In March 2023, 34 associated cases of iatrogenic botulism were detected in Germany (30 cases), Switzerland (two cases), Austria (one case), and France (one case). An alert was rapidly disseminated via European Union networks and communication platforms (Food- and Waterborne Diseases and Zoonoses Network, EpiPulse, Early Warning and Response System) and the International Health Regulation mechanism; the outbreak was investigated in a European collaboration. We traced sources of the botulism outbreak to treatment of weight loss in Türkiye, involving intragastric injections of botulinum neurotoxin. Cases were traced using a list of patients who had received this treatment. Laboratory investigations of the first 12 German cases confirmed nine cases. The application of innovative and highly sensitive endopeptidase assays was necessary to detect minute traces of botulinum neurotoxin in patient sera. The botulism notification requirement for physicians was essential to detect this outbreak in Germany. The surveillance case definition of botulism should be revisited and inclusion of cases of iatrogenic botulism should be considered as these cases might lack standard laboratory confirmation yet warrant public health action. Any potential risks associated with the use of botulinum neurotoxins in medical procedures need to be carefully balanced with the expected benefits of the procedure.