UNIVERSIDAD NACIONAL DEL NORDESTE

FACULTAD DE MEDICINA
CTEDRA INGLS II
Apellido y nombres:L.U.N:
BOTULISM
Botulism (Latin, botulus, "sausage") is a rare, but serious paralytic illness caused by a nerve toxin, botulin, that is produced by the
bacterium Clostridium botulinum. Botulinic toxin is one of the most powerful known toxins: about one microgram is lethal to humans. It
acts by blocking nerve function and leads to respiratory and musculoskeletal paralysis. (1)
There are three main kinds of botulism:

Foodborne botulism is caused by eating foods that contain the botulinum toxin.
Infant botulism is caused by consuming the spores of the botulinum bacteria, which then grow in the intestines and release
toxin.
Wound botulism is caused by toxin produced from a wound infected with Clostridium botulinum. This is the rarest type of
botulism.

All forms of botulism can be fatal and are considered medical emergencies. Foodborne botulism can be especially dangerous as a
public health problem because many people can be poisoned from a single contaminated food source. (2)
In the United States an average of 110 cases of botulism are reported each year. Of these, approximately 25% are foodborne, 72% are
infant botulism, and 3% are wound botulism. Outbreaks of foodborne botulism involving two or more persons occur during most years
and usually are caused by eating contaminated home-canned foods. The number of cases of foodborne and infant botulism has
changed little in recent years, but wound botulism has increased because of the use of black tar heroin, especially in California.[1] In
July 2007, a widespread recall was initiated due to botulism contamination of food manufactured by Castleberry's Food Company. [2]
Shortly after in August 2007, the FDA issued a warning of botulism risk from canned French cut green beans manufactured by
Lakeside Foods Inc, of Manitowoc, Wisconsin.[3]
Symptoms
Food-borne and wound botulism
Food-Borne

Classic symptoms of food-borne botulism usually occur between 1236 hours after consuming the botulinum toxin. However,
they can occur as early as 6 hours or as late as 10 days after.
Wound botulism has a longer incubation period, usually between 414 days.

Common symptoms of either form usually include dry mouth, difficulty swallowing, slurred speech, drooping eyelids, muscle weakness,
double and/or blurred vision, vomiting, blatter and sometimes diarrhea. These symptoms may progress to cause paralytic ileus with
severe constipation, and eventually body paralysis. The respiratory muscles are affected as well, which may cause death due to
respiratory failure. These are all symptoms of the muscle paralysis caused by the bacterial toxin.
In all cases illness is caused by the toxin made by C. botulinum, not by the bacterium itself. The pattern of damage occurs because the
toxin affects nerves that are firing more often.[4]
Infant botulism
Infant botulism (first recognized in 1976) is the most common form of the ailment in the United States, but is rarely diagnosed in other
countries. It affects about 100 infants per year in the United States, with the majority in the state of California (5060%). Infants less
than 12 months of age are susceptible, with 95% of cases occurring between the ages of 3 weeks and 6 months of age at
presentation. The mode of action of this form is through colonization by germinating spores in the gut of an infant. The first symptom is
usually constipation, followed by generalized weakness, loss of head control and difficulty feeding. Like the other forms of botulism, the
symptoms are caused by the absorption of botulinum toxin, and typically progress to a symmetric descending flaccid paralysis. Death
is the eventual outcome unless the infant receives artificial ventilation. (3)

(4) Honey, corn syrup, and other sweeteners are potentially dangerous for infants. This is partly because the digestive juices of an
infant are less acidic than older children and adults, and may be less likely to destroy ingested spores. In addition, young infants do not
yet have sufficient numbers of resident microbiota in their intestines to competitively exclude C. botulinum. Unopposed in the small
intestine, the warm body temperature combined with an anaerobic environment creates a medium for botulinum spores to germinate,
divide and produce toxin. Thus, C. botulinum is able to colonize the gut of an infant with relative ease, whereas older children and
adults are not typically susceptible to ingested spores. C. botulinum spores are widely present in the environment, including honey. For
this reason, it is advised that neither honey, nor any other sweetener, be given to children until after 12 months. Nevertheless, the
majority of infants with botulism have no history of ingestion of honey, and the exact source of the offending spores is unclear about
85% of the time. Spores present in the soil are a leading candidate for most cases, and often a history of construction near the home of
an affected infant may be obtained.
Botulinum toxin
Botulinum toxin blocks the release of acetylcholine from nerve endings thus arresting their function. The C. botulinum bacterium
produces toxin in an anaerobic environment, and the toxin is unstable to heating, so poisoning generally occurs from the use of
improperly bottled or canned foods: typical instances of botulism would be home-bottled preserves used in salads. An unusual example
of botulism occurred in Britain in the exceptionally hot, dry summer of 1976, when river levels dropped so low in some areas that
swans ingested material from anaerobic layers in a river (normally out of their reach), and were struck by botulism symptoms.
(5) Botulinum toxin is used cosmetically to reduce facial wrinkles or excessive transpiration, and is commercially known as Botox.
Cases of inadvertent botulism have occurred due to overdose or accidental intravenous injection of Botox.
Diagnosis
Physicians may consider the diagnosis if the patient's history and physical examination suggest botulism. However, these clues are
often not enough to allow a diagnosis of botulism. Other diseases such as Guillain-Barr syndrome, stroke, and myasthenia gravis can
appear similar to botulism, and special tests may be needed to exclude these other conditions. These tests may include a brain scan,
cerebrospinal fluid examination, nerve conduction test (electromyography, or EMG), and an Edrophonium Chloride (Tensilon) test for
myasthenia gravis. The most direct way to confirm the diagnosis is to demonstrate the botulinum toxin in the patient's serum or stool by
injecting serum or stool into mice and looking for signs of botulism that can be blocked by specific antisera. (6)
Treatment
(7) The respiratory failure and paralysis that occur with severe botulism may require a patient to be on a breathing machine for weeks,
plus intensive medical and nursing care. After several weeks, the paralysis slowly improves. If diagnosed early, foodborne and wound
botulism can be treated by inducing passive immunity with a horse-derived antitoxin, which blocks the action of toxin circulating in the
blood.[5] This can prevent patients from worsening, but recovery still takes many weeks. Physicians may try to remove contaminated
food still in the gut by inducing vomiting or by using enemas. Wounds should be treated, usually surgically, to remove the source of the
toxin-producing bacteria. Good supportive care in a hospital is the mainstay of therapy for all forms of botulism.
Besides supportive care, infant botulism can be treated with human botulism immune globulin (BabyBIG), when available. Supply is
extremely limited, but is available through the California Department of Health Services. This dramatically decreases the length of
illness for most infants. (8) Paradoxically, antibiotics (especially aminoglycosides or clindamycin) may cause dramatic acceleration of
paralysis as the affected bacteria release toxin. Visual stimulation should be performed during the time the infant is paralyzed as well,
in order to promote the normal development of visual pathways in the brain during this critical developmental period.
Furthermore each case of food-borne botulism is a potential public health emergency in that it is necessary to identify the source of the
outbreak and ensure that all persons who have been exposed to the toxin have been identified, and that no contaminated food
remains. (9)
There are two primary Botulinum Antitoxins available for treatment of wound and foodborne botulism. Trivalent (A,B,E) Botulinum
Antitoxin is derived from equine sources utilizing whole antibodies (Fab & Fc portions). This antitoxin is available from the local health
department via the CDC. The second antitoxin is heptavalent (A,B,C,D,E,F,G) Botulinum Antitoxin which is derived from "despeciated"
equine IgG antibodies which have had the Fc portion cleaved off leaving the F(ab')2 portions. This is a less immunogenic antitoxin that
is effective against all known strains of botulism where not contraindicated. This is available from the US Army. On June 1, 2006 the
US Department of Health and Human Services awarded a $363 million contract with Cangene Corporation for 200,000 doses of
Heptavalent Botulinum Antitoxin over five years for delivery into the Strategic National Stockpile beginning in 2007.[6]

Complications
Botulism can result in death due to respiratory failure. However, in the past 50 years, the proportion of patients with botulism who die
has fallen from about 50% to 8% due to improved supportive care. A patient with severe botulism may require a breathing machine as
well as intensive medical and nursing care for several months. Patients who survive an episode of botulism poisoning may have fatigue
and shortness of breath for years and long-term therapy may be needed to aid their recovery.
Infant botulism has no long-term side effects, but can be complicated by nosocomial adverse events. The case fatality rate is less than
1% for hospitalized infants with botulism.
While commercially canned goods are required to undergo a "botulinum cook" at 121C (250 F) for 3 minutes and so rarely cause
botulism, there have been notable exceptions such as the 1978 Alaskan salmon outbreak and the 2007 Castleberry's Food Co.
outbreak. Foodborne botulism has more frequently been from home-canned foods with low acid content, such as carrot juice,
asparagus, green beans, beets, and corn. However, outbreaks of botulism have resulted from more unusual sources. In July, 2002,
fourteen Alaskans ate muktuk (whale meat) from a beached whale, and eight of them developed symptoms of botulism, two of them
requiring mechanical ventilation. Other sources of infection include garlic or herbs[ stored covered in oil, chili peppers, improperly
handled baked potatoes wrapped in aluminium foil ], and home-canned or fermented fish. Persons who do home canning should follow
strict hygienic procedures to reduce contamination of foods. Oils infused with garlic or herbs should be refrigerated. Potatoes which
have been baked while wrapped in aluminum foil should be kept hot until served or refrigerated [8]. Because the botulism toxin is
destroyed by high temperatures, home-canned foods are best boiled for 10 minutes before eating. Metal cans containing food in which
bacteria, possibly botulinum, are growing may bulge outwards due to gas production from bacterial growth; such cans should be
thrown away. Any container of food which has been heat-treated and then assumed to be airtight which shows signs of not being so
(e.g., metal cans with pinprick holes from rust or mechanical damage) should also be discarded.
Wound botulism can be prevented by promptly seeking medical care for infected wounds, and by avoiding punctures by unsterile
things such as needles used for street drug injections. It is currently being researched at USAMIRIID under BSL-4.

UNIVERSIDAD NACIONAL DEL NORDESTE

FACULTAD DE MEDICINA
CTEDRA INGLS II
Apellido y nombres:L.U.N:
CRITERIOS DE EVALUACION:
Comprender consignas.
Utilizar vocabulario especifico y estructuras apropiadas.
Producir textos coherentes, cohesivos y significativos.
Extraer/inferir informacin requerida.
Usar tinta y letra legible.

BOTULISM
Botulism (Latin, botulus, "sausage") is a rare, but serious paralytic illness caused by a nerve toxin, botulin, that is produced by the bacterium
Clostridium botulinum. Botulinic toxin is one of the most powerful known toxins: about one microgram is lethal to humans. It acts by blocking nerve
function and leads to respiratory and musculoskeletal paralysis.
There are three main kinds of botulism:

Foodborne botulism is caused by eating foods that contain the botulinum toxin.
Infant botulism is caused by consuming the spores of the botulinum bacteria, which then grow in the intestines and release toxin.
Wound botulism is caused by toxin produced from a wound infected with Clostridium botulinum. This is the rarest type of botulism.

All forms of botulism can be fatal and are considered medical emergencies. Foodborne botulism can be especially dangerous as a public health
problem because many people can be poisoned from a single contaminated food source.
In the United States an average of 110 cases of botulism are reported each year. Of these, approximately 25% are foodborne, 72% are infant
botulism, and 3% are wound botulism. Outbreaks of foodborne botulism involving two or more persons occur during most years and usually are
caused by eating contaminated home-canned foods. The number of cases of foodborne and infant botulism has changed little in recent years , but
wound botulism has increased because of the use of black tar heroin, especially in California. In July 2007, a widespread recall was initiated due to
botulism contamination of food manufactured by Castleberry's Food Company. Shortly after in August 2007, the FDA issued a warning of botulism
risk from canned French cut green beans manufactured by Lakeside Foods Inc, of Manitowoc, Wisconsin.
Symptoms
Food-borne and wound botulism
Food-Borne

Classic symptoms of food-borne botulism usually occur between 1236 hours after consuming the botulinum toxin. However, they can
occur as early as 6 hours or as late as 10 days after.
Wound botulism has a longer incubation period, usually between 414 days.

Common symptoms of either form usually include dry mouth, difficulty swallowing, slurred speech, drooping eyelids, muscle weakness, double
and/or blurred vision, vomiting, blatter and sometimes diarrhea. These symptoms may progress to cause paralytic ileus with severe constipation,
and eventually body paralysis. The respiratory muscles are affected as well, which may cause death due to respiratory failure. These are all
symptoms of the muscle paralysis caused by the bacterial toxin.
In all cases illness is caused by the toxin made by C. botulinum, not by the bacterium itself. The pattern of damage occurs because the toxin affects
nerves that are firing more often.
Infant botulism
Infant botulism (first recognized in 1976) is the most common form of the ailment in the United States, but is rarely diagnosed in other countries. It
has affected about 100 infants per year in the United States, with the majority in the state of California (5060%). Infants less than 12 months of age
are susceptible, with 95% of cases occurring between the ages of 3 weeks and 6 months of age at presentation. The mode of action of this form is
through colonization by germinating spores in the gut of an infant. The first symptom is usually constipation, followed by generalized weakness, loss
of head control and difficulty feeding. Like the other forms of botulism, the symptoms are caused by the absorption of botulinum toxin, and typically
progress to a symmetric descending flaccid paralysis. Death is the eventual outcome unless the infant receives artificial ventilation.

Honey, corn syrup, and other sweeteners are potentially dangerous for infants. This is partly because the digestive juices of an infant are less acidic
than older children and adults, and may be less likely to destroy ingested spores. In addition, young infants do not yet have sufficient numbers of
resident microbiota in their intestines to competitively exclude C. botulinum. Unopposed in the small intestine, the warm body temperature combined
with an anaerobic environment creates a medium for botulinum spores to germinate, divide and produce toxin. Thus, C. botulinum is able to colonize
the gut of an infant with relative ease, whereas older children and adults are not typically susceptible to ingested spores. C. botulinum spores are
widely present in the environment, including honey. For this reason, it is advised that neither honey, nor any other sweetener, be given to children
until after 12 months. Nevertheless, the majority of infants with botulism have no history of ingestion of honey, and the exact source of the offending
spores is unclear about 85% of the time. Spores present in the soil are a leading candidate for most cases, and often a history of construction near
the home of an affected infant may be obtained.
Botulinum toxin
Botulinum toxin blocks the release of acetylcholine from nerve endings thus arresting their function. The C. botulinum bacterium produces toxin in an
anaerobic environment, and the toxin is unstable to heating, so poisoning generally occurs from the use of improperly bottled or canned foods:
typical instances of botulism would be home-bottled preserves used in salads. An unusual example of botulism occurred in Britain in the
exceptionally hot, dry summer of 1976, when river levels dropped so low in some areas that swans ingested material from anaerobic layers in a river
(normally out of their reach), and were struck by botulism symptoms.
Botulinum toxin is used cosmetically to reduce facial wrinkles or excessive transpiration, and is commercially known as Botox. Cases of inadvertent
botulism have occurred due to overdose or accidental intravenous injection of Botox.
Diagnosis
Physicians will consider the diagnosis if the patient's history and physical examination suggest botulism. However, these clues are often not enough
to allow a diagnosis of botulism. Other diseases such as Guillain-Barr syndrome, stroke, and myasthenia gravis can appear similar to botulism, and
special tests may be needed to exclude these other conditions. These tests may include a brain scan, cerebrospinal fluid examination, nerve
conduction test (electromyography, or EMG), and an Edrophonium Chloride (Tensilon) test for myasthenia gravis. The most direct way to confirm the
diagnosis is to demonstrate the botulinum toxin in the patient's serum or stool by injecting serum or stool into mice and looking for signs of botulism
that can be blocked by specific antisera.
Treatment
The respiratory failure and paralysis that occur with severe botulism may require a patient to be on a breathing machine for weeks, plus intensive
medical and nursing care. After several weeks, the paralysis slowly improves. If diagnosed early, foodborne and wound botulism can be treated by
inducing passive immunity with a horse-derived antitoxin, which blocks the action of toxin circulating in the blood. [5] This can prevent patients from
worsening, but recovery still takes many weeks. Physicians may try to remove contaminated food still in the gut by inducing vomiting or by using
enemas. Wounds should be treated, usually surgically, to remove the source of the toxin-producing bacteria. Good supportive care in a hospital is
the mainstay of therapy for all forms of botulism.
Besides supportive care, infant botulism can be treated with human botulism immune globulin (BabyBIG), when available. Supply is extremely
limited, but is available through the California Department of Health Services. This dramatically decreases the length of illness for most infants.
Paradoxically, antibiotics (especially aminoglycosides or clindamycin) may cause dramatic acceleration of paralysis as the affected bacteria release
toxin. Visual stimulation should be performed during the time the infant is paralyzed as well, in order to promote the normal development of visual
pathways in the brain during this critical developmental period.
Furthermore each case of food-borne botulism is a potential public health emergency in that it is necessary to identify the source of the outbreak and
ensure that all persons who have been exposed to the toxin have been identified, and that no contaminated food remains.
There are two primary Botulinum Antitoxins available for treatment of wound and foodborne botulism. Trivalent (A,B,E) Botulinum Antitoxin is derived
from equine sources utilizing whole antibodies (Fab & Fc portions). This antitoxin is available from the local health department via the CDC. The
second antitoxin is heptavalent (A,B,C,D,E,F,G) Botulinum Antitoxin which is derived from "despeciated" equine IgG antibodies which have had the
Fc portion cleaved off leaving the F(ab')2 portions. This is a less immunogenic antitoxin that is effective against all known strains of botulism where
not contraindicated. This is available from the US Army. On June 1, 2006 the US Department of Health and Human Services awarded a $363 million
contract with Cangene Corporation for 200,000 doses of Heptavalent Botulinum Antitoxin over five years for delivery into the Strategic National
Stockpile beginning in 2007.
Complications
Botulism can result in death due to respiratory failure. However, in the past 50 years, the proportion of patients with botulism who die has fallen from
about 50% to 8% due to improved supportive care. A patient with severe botulism may require a breathing machine as well as intensive medical and
nursing care for several months. Patients who survive an episode of botulism poisoning may have fatigue and shortness of breath for years and
long-term therapy may be needed to aid their recovery.
Infant botulism has no long-term side effects, but can be complicated by nosocomial adverse events. The case fatality rate is less than 1% for
hospitalized infants with botulism.

While commercially canned goods are required to undergo a "botulinum cook" at 121C (250 F) for 3 minutes and so rarely cause botulism, there
have been notable exceptions such as the 1978 Alaskan salmon outbreak and the 2007 Castleberry's Food Co. outbreak. Foodborne botulism has
more frequently been from home-canned foods with low acid content, such as carrot juice, asparagus, green beans, beets, and corn. However,
outbreaks of botulism have resulted from more unusual sources. In July, 2002, fourteen Alaskans ate muktuk (whale meat) from a beached whale,
and eight of them developed symptoms of botulism, two of them requiring mechanical ventilation. Other sources of infection include garlic or herbs,
stored covered in oil, chili peppers, improperly handled baked potatoes wrapped in aluminum foil, and home-canned or fermented fish. Persons who
do home canning should follow strict hygienic procedures to reduce contamination of foods. Oils infused with garlic or herbs should be refrigerated.
Potatoes which have been baked while wrapped in aluminum foil should be kept hot until served or refrigerated. Because the botulism toxin is
destroyed by high temperatures, home-canned foods are best boiled for 10 minutes before eating. Metal cans containing food in which bacteria,
possibly botulinum, are growing may bulge outwards due to gas production from bacterial growth; such cans should be thrown away. Any container
of food which has been heat-treated and then assumed to be airtight which shows signs of not being so (e.g., metal cans with pinprick holes from
rust or mechanical damage) should also be discarded.
Wound botulism can be prevented by promptly seeking medical care for infected wounds, and by avoiding punctures by unsterile things such as
needles used for street drug injections. It is currently being researched at USAMIRIID under BSL-4.
ANSWER THESE QUESTIONS IN SPANISH
1.
2.

What is Botulism? What does it lead to? (10)

How many kinds of botulism are there? Explain Foodborne Botulism and say why it is especially dangerous. (10)

3.

Which are the symptoms of Infant Botulism? (10)

4.

Why are honey, corn syrup, and other sweeteners potentially dangerous for infants? (10)

5.

What is Botulism Toxin used for? What is its commercial name? (5)

6.

How is Botulism diagnosed? (5)

7.

How are the respiratory failure and paralysis treated? (10)

8.

Are anitbiotics a good option for botulism treatment? Why? (10)

9.

Why is food-borne botulism considered a potential public health emergency? What should be done in those cases? (10)

10. Mention at least two sources of infection of botulism. (10)

CLASIFY THE UNDERLINED SENTENCES INTO THE TABLE ACCORDING TO THEIR GRAMMATICAL TENSE: (10)

Present Simple
Perfect Tense
Modal verb
Future Form
Passive Voice

Glossary
Spores: esporas
Stool: excremento
Outbreak: origen

Canned goods: comida enlatada /conservas