Botulism causes and treatment

 Botulism 

Caused by the gram-positive, anaerobic bacteria Clostridium botulinum, botulism is a rare but severe form of poisoning. C. botulinum is found in soil and untreated water worldwide. The bacteria can also be found in undercooked and improperly preserved or canned foods—especially those with a low acid content. C. botulinum sometimes occurs normally in the stool of infants. It is one of the most potent bacteria known: If evenly distributed, as little as 1 g can kill more than 1 million people. 

There are three main types of botulism, each characterized by the way the disease is transmitted: foodborne botulism, wound botulism, and infant botulism. The number of reported cases worldwide has been decreasing, mostly because of improved canning and food preservation methods.According to the National Institutes of Health, approximately 145 cases of botulism are seen in the United States every year. Of these, almost 65% are infant botulism. However, the incidence of wound botulism, which was once exceedingly rare, is now on the rise, presumably due to increased injectable drug use. 

ALERT 

All forms of botulism can be fatal and are considered medical emergencies. 

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Initially used to treat conditions such as cervical dystonia and blepharospasm, two botulinum toxin preparations are licensed in the United States by the Food and Drug Administration. However, on- and off-label use of these preparations has grown. Botulinum toxin A is now available by prescription for therapeutic and cosmetic use. 

The formulation is normally highly diluted. In 2004, the Centers for Disease Control and Prevention (CDC) confirmed four cases of botulism in adults following cosmetic injection of an unlicensed and highly concentrated botulinum toxin A preparation. All four individuals became severely ill, but they all survived. 

ALERT Botulinum toxin is also considered a major biological weapon.Therefore, with any outbreak of botulism, bioterrorism must be considered. 

CAUSES 

C. botulinum produces neurotoxin-releasing spores that, when ingested or introduced into a wound, may lead to severe poisoning. The foods most commonly contaminated are home-canned vegetables, cured pork and ham,smoked or raw fish, and honey and corn syrup. Infant botulism occurs when a child ingests the C. botulinum spores that then release the neurotoxin in the intestine.

 PREVENTION 

Never give honey or corn syrup to an infant younger than 1, not even a small amount on a pacifier. COMPLICATIONS Due to the associated weakness, the risk of aspiration is high. Weakness and nervous system problems can become permanent. Death can result if the patient does not receive prompt treatment. 

ASSESSMENT FINDINGS 

Symptoms often appear 12 to 36 hours after ingestion of the contaminated food, although symptoms can be apparent as early as 6 hours or as late as 10 days after ingestion. Generally, the earlier the symptoms appear, the more critical and severe the illness will be. Severity depends on the amount of toxin ingested and the patient’s degree of immunocompromise. In adults, the most common symptoms include double or blurred vision, droopy eyelids, dry mouth, difficulty swallowing and talking, difficulty breathing, and flaccid paralysis that moves down the body. Deep tendon reflexes are decreased or absent. In infants, symptoms include weakness and lethargy, constipation, weak cry, poor feeding and sucking, and respiratory distress.

DIAGNOSTIC TESTS 

◗ A toxicology screen may identify C. botulinum. 

◗ Stool culture may identify C. botulinum. ◗ The suspected food may also be cultured to isolate C. botulinum. ◗ Electromyography will show little response to nerve stimulation in the presence of botulism. ◗ Diagnostic tests should be conducted as needed to rule out diseases that may be confused with botulism, such as myasthenia gravis and Guillain-Barré syndrome. ◗ A mouse-inoculation test will be positive and is the most direct way to confirm a diagnosis of botulism. 

TREATMENT ِ

Botulinus antitoxin, available from the CDC, is administered either I.V. or I.M., although not usually to infants. In infants, the bacteria must be removed by inducing vomiting or by giving an enema. In wound botulism, the toxin is usually removed surgically. For patients with swallowing difficulties, I.V. fluid can be administered, or a nasogastric tube can be inserted until the patient recovers suff iciently. Respiratory distress may require endotracheal intubation. Recovery may take weeks or months as axons on the nerves are regenerated. Fatigue and shortness of breath may continue for years.

 SAFETY Botulism is not contagious and cannot be transmitted from person to person.

 NURSING CONSIDERATIONS 

◗ Obtain a careful history of foods eaten in the past several days. Ask about the health status of other family members with similar food histories. 

◗ Monitor respiratory and cardiac function carefully.

 ◗ Perform frequent neurologic checks.

 ◗ Purge the GI tract as ordered.

 ◗ If giving the botulinus antitoxin, check the patient’s allergies, especially to horses, because the antitoxin is horse serum. When giving the antitoxin, perform a skin test first, then watch for signs of allergic reaction. 

◗ Prevent secondary infection by practicing standard precautions. 

◗ Report all cases of botulism to the state health department or the CDC. 

◗ Provide emotional support to the patient and family. 

Patient teaching

 ◗ Educate the patient and family about the importance of proper hand hygiene. 

◗ Teach the patient and family to cook food thoroughly before ingesting.

 ◗ Instruct the patient who eats homecanned food to boil the food for 10 minutes before eating to ensure that it is safe to consume. Tell the patient and family to not taste-test any food that is questionable. ِ

◗ Teach patients and families to see their doctors promptly for infected wounds and to avoid injectable street drugs.ِِ

 PREVENTION 

Baked potatoes that were wrapped in aluminum foil should be kept hot until served, or refrigerated. Oils that contain garlic or herbs should be refrigerated. If doing home canning, follow strict hygiene methods to prevent or kill C. botulinum, their spores, and the neurotoxin. Bulging cans or abnormal-smelling preserved foods should not be ingested.