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B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential.

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1 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Botulism Angela Houston Dr Angela Houston is a specialist registrar in Infectious Diseases, Microbiology and Virology in London/ South Coast. Edited by Prof Tom Solomon and Dr Agam Jung This session provides an overview of botulism. Clinical presentation, differential diagnosis, treatment and prevention.

2 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Learning Objectives By the end of this session you will be able to: State the impact of botulism worldwide, microbiology and transmission Describe the actions of botulinum toxin Recognise the clinical presentation of botulism and differential diagnosis Specify the laboratory and clinical diagnosis of botulism Explain the treatment of botulism

3 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Overview In this session you will learn about the neurological presentation of botulism. You will learn about the microbiology, routes of transmission, presentation, treatment and prevention of botulism and infections caused by bacterial neurotoxins.

4 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Botulism Microbiology I Botulism is a rare and potentially fatal disease caused by a highly potent neurotoxin released by the anaerobic spore forming bacterium Clostridium botulinum and, rarely by Clostridium baratii and Clostridium butyricum. There are seven neurotoxins (A-G). Illness in humans is usually caused by types A, B or E, or rarely by F. All toxins block the release of acetylcholine at the neuromuscular junction and produce the same neurological syndrome. Clostridium botulinum is present in the soil and environment and is responsible for three naturally occurring forms of botulism, all of which present with the same neurological features but depend on mode of acquisition.

5 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Botulism Microbiology II Clostridium botulinum – CDC Public Health Image Library #2107

6 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Botulism can be transferred by: Food-borne from ingestion of contaminated food with preformed toxin Infantile botulism caused by ingestion of spores which colonise the gastrointestinal tract and produce toxin in vivo Wound botulism caused by infection of a wound with Clostridium botulinum and production of toxin in vivo There is also a further possibility that botulism may occur as a result of deliberate release or as accidental exposure following miss-injection of therapeutic neurotoxin. The neurological syndrome produces acute, symmetrical descending flaccid paralysis. Transmission

7 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Food-born botulism occurs from ingestion of preformed toxin present in food which has been stored in airtight (anaerobic) conditions. Cases have mainly occurred in sporadic outbreaks and the Health Protection Agency (HPA) reports 33 cases in the UK between of which there were three fatalities. Recent cases have occurred amongst Polish immigrants who eat home preserved sausages and pickles stored in jars. Very rarely, intestinal colonisation similar to infant botulism occurs in adults, usually with an underlying reason, such as gastrointestinal abnormalities. Prodromal symptoms begin within hours of ingesting the preformed toxin. Types: Food-borne Botulism

8 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Gastrointestinal colonisation occurs when babies ingest environmental spores of Clostridium botulinum which germinate within the gastrointestinal tract producing in vivo toxin production. Babies present anytime from 1 week to 12 months of age (usually < 6 months) with non specific symptoms including: Weakness Hypotonia Hyporeflexia Bulbar palsies Constipation Poor feeding Dehydration Disease progression in children can be very rapid. The disease presentation is variable and is likely to reflect the differences in bacterial load and host immunity in infants of different ages. Only six infantile cases have been reported to the HPA from with no fatalities. Types: Infantile Botulism

9 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Wound botulism was first described in the USA in the 1950s but the last decade has seen a huge increase in the number of cases and now is the most common form of botulism seen in the developed world. 163 cases have been reported to the HPA in the UK from reflecting the increase in intravenous drug use (IVDU). The disease is seen almost exclusively in injecting heroin users who use 'skin popping' as a route of drug administration. Types: Wound Botulism

10 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Heroin used in the UK originates predominantly from Asia and arrives as a powder which has undergone a number of processing steps including 'cutting' with bulking agents en route. Any of these stages may result in the accidental introduction of clostridium botulinum spores from contaminated material. In order to inject the drug, it is mixed with an acid usually citric acid and heated briefly. In IVDUs with limited venous access the material is injected directly into the skin or muscle ('skin popping'). The acid results in local necrosis which produces anaerobic conditions ideal for germination of Clostridium botulinum and toxin production. It is not seen in IVDUs who inject directly into veins as the spores do not have time to germinate in anaerobic conditions. Types: Drug Use

11 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Regardless of mode of entry to the human body, the neurotoxin disseminates widely in throughout the vascular system and binds irreversibly to the presynaptic sides of peripheral cholinergic synapses at ganglia and neuromuscular junction. Actions of Botulinum Neurotoxin I

12 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions The heavy chain of the toxin binds to the receptors, allowing the light chain to translocate into the nerve cell via receptor mediated-endocytosis. Inside the cytoplasm, the toxin produces an irreversible disruption in stimulation-induced acetylcholine release by that presynaptic nerve terminal. Recovery Recovery is slow as new synaptic terminals must form from the original nerve plate, a process that takes approximately six months. Adrenergic nerves are unaffected and the toxin seems unable to cross the blood brain barrier so limiting damage to the peripheral cholinergic system. If onset is very rapid, there may be no symptoms before sudden respiratory paralysis occurs. Actions of Botulinum Neurotoxin II

13 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Presentation Adults patients infected with the botulinum neurotoxin present with similar clinical features irrespective of mode of acquisition: Bilateral cranial nerve palsies Descending flaccid paralysis Blurred or double vision Dysphagia and a dry mouth (often the first complaints) progressing to a symmetrical flaccid paralysis and respiratory failure Clinical Presentation of Botulism

14 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions The following are diseases with similar clinical features to botulism: Botulism Guillain–Barre syndrome (GBS) Miller Fisher variant of GBS Myasthenia gravis Viral encephalitides Tick paralysis Paralytic shellfish poisoning Rabies Differential Diagnosis I

15 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Botulism Acute bilateral cranial neuropathies and symmetrical descending weakness No fever unless intercurrent infection Only sensory deficit may be blurred vision History of exposure – ingestion IDU or a traumatic wound Guillain-Barre syndrome (GBS) Antecedent febrile illness Ascending symmetrical paralysis Loss of sensation, parasthesia, pain, loss of reflexes Electromyograph may help differentiate Antiganglioside antibody may be elevated in CSF or serum with GBS or Miller Fisher No augmentation of modified action potential with repetitive nerve stimulation at Hz in contrast to botulism Differential Diagnosis II

16 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Miller Fisher variant of GBS Antecedent febrile illness Ascending paralysis and parasthaesia Early loss of reflexes Internal and external opthalmoplegia with ataxia which is more marked than limb weakness Myasthenia gravis Muscular fatigability Resolution of paralysis with Tensilon (but some improvement seen in some cases of botulism) Recurrent paralysis Sustained response to anticholinesterase therapy Spinal/paralytic poliomyelitis, almost never sensory loss Antecedent febrile illness, asymmetrical paralysis Altered CSF Meningeal irritation Differential Diagnosis III

17 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Viral encephalitides Fever and altered mental state Abnormal CSF Asymmetric weakness EEG findings Cerebrovascular accident Sensory deficits Asymmetric hyperactive deep tendon reflexes Tick paralysis Travel to endemic area (Australia, USA) Presence of femal tick, may be hidden in long hair Parasthesia of affected extremities Ascending paralysis Loss of deep tendon reflexes Rare cranial nerve involvement Occasional cerebellar ataxia Differential Diagnosis IV

18 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Paralytic shellfish poisoning History of consumption of shellfish (or rarely fish) Incubation of 1 hour Numbness of face and lips Parasthesis Normal reflexes Respiratory paralysis Rabies Not necessarily following a recent bite Can be months Ascending paralysis Incoordination Pharyngeal spasm particularly on drinking buy not due to a breeze of air Differential Diagnosis V

19 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Diagnosis The diagnosis of botulism is based on clinical suspicion. Demonstration of the toxin in serum can be helpful. Laboratory and Clinical Diagnosis of Botulism I Learning Bite: Always seek advise from an Infectious diseases specialist and ITU.

20 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Food-borne botulism In food-borne botulism, toxin is present in serum or faeces in >50% of cases within one day of onset, but <25% after 3 days C. botulinum will be present in the faeces for longer which may be helpful diagnostically Toxin can be isolated in faecal samples in >70% of cases within 2 days and 40% 10 days after onset of food poisoning Laboratory and Clinical Diagnosis of Botulism II

21 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Wound botulism In wound botulism, toxin is isolated in the blood in 40% of suspected cases It is important to very carefully examine patients for wounds that may need debridement no matter how small Toxin detection requires 10ml serum sample (ideally before any antitoxin is administered). This is measured by a bioassay in mice. The presence of toxin confirms the clinical diagnosis Serum samples are not so helpful in infantile botulism Laboratory and Clinical Diagnosis of Botulism III

22 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Treatment of botulism should include: Early administration of botulinum antitoxin (if indicated) Search for and debride any wound no matter how trivial Give antibiotics if wound present Supportive treatment The Treatment of Botulism I

23 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Antitioxin Antitoxin is an effective treatment and will prevent further progression of symptoms but will not reverse established paralysis. If administered early it may neutralise any circulating toxin There are a number of antitoxin products available all of which have been derived from pooled animal immunoglobulin If the patient continues to deteriorate the dose may be repeated within 24 hours Since antitoxin is derived from animal immunoglobulin it carries a risk of allergic reactions such as anaphylaxis and serum sickness The Treatment of Botulism II

24 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions The Treatment of Botulism III Learning Bite: Any case of suspected Botulism should be reported promptly to the HPA. With antitoxin and good supportive treatment, recovery is to be expected although it may take weeks or months, so prolonged hospital admissions are likely.

25 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Key Points Botulism is a rare but potentially life threatening disease caused by neurotoxins of Clostridium botulinum Three endogenous forms exist. Food-bourne, infantile and wound botulism which is now the commonest form seen with the rise in intravenous drug users Botulinum toxin binds irreversibly to the presynaptic membrane at the motor endplate inhibiting release of acetylcholeine Classically presents with bilateral cranial nerve palsies and an acute, symmetrical, descending flaccid paralysis in the absence of fever or cognitive disturbance Diagnosis is clinical but can be aided by identifying Botulinum toxin in serum or stool samples Treatment is supportive and antitoxin can be effective in preventing further progression if given early. Wounds infected with C. Botulinum need urgent debridement and antibiotic treatment

26 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Summary Having completed this session you will now be able to: State the impact of botulism worldwide, microbiology and transmission Describe the actions of botulinum toxin Recognise the clinical presentation of botulism and differential diagnosis Specify the laboratory and clinical diagnosis of botulism Explain the treatment of botulism

27 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions References and further reading Montecucco, C. and G. Schiavo, Mechanism of action of tetanus and botulinum neurotoxins. Molecular microbiology, (1): p Brett, M., G. Hallas, and O. Mpamugo, Wound botulism in the UK and Ireland. Journal of medical microbiology, (6): p Cherington, M. Botulism: update and review. 2004: [New York]: Thieme-Stratton Inc.,[c1981]. McLauchlin, J., K. Grant, and C. Little, Food-borne botulism in the United Kingdom. Journal of Public Health, (4): p Lindstrom, M. and H. Korkeala, Laboratory diagnostics of botulism. Clinical microbiology reviews, (2): p Bleck, TP. Clostridium botulinum (botulism). In: Principles and Practice of Infectious Diseases, 6th ed. Mandell, GL, Bennett, JE, Dolin, R, (Eds), Churchill Livingstone, Philadelphia, PA 2005, p Health Protection Agency Website. Antitoxin and advice are available from the duty doctor at the Health Protection Agency, Centre for infections in the UK. For infant botulism a human derived Botulinum immune Globulin BabyBIG® is available from the Infant Botulism Treatment and Prevention Program (IBTPP) California USA.

28 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 1 Which of the statements are correct with regards to the botulinum toxin? a)Botulinum toxin is one of the most potent neurotoxins knownBotulinum toxin is one of the most potent neurotoxins known b)Botulism is most commonly caused by the Botulinum neurotoxins A and CBotulism is most commonly caused by the Botulinum neurotoxins A and C c)Causes inhibition of the action of GABACauses inhibition of the action of GABA d)Affects the peripheral and central nervous systemAffects the peripheral and central nervous system Which of the statements are correct with regards to the botulinum toxin? a)Botulinum toxin is one of the most potent neurotoxins knownBotulinum toxin is one of the most potent neurotoxins known b)Botulism is most commonly caused by the Botulinum neurotoxins A and CBotulism is most commonly caused by the Botulinum neurotoxins A and C c)Causes inhibition of the action of GABACauses inhibition of the action of GABA d)Affects the peripheral and central nervous systemAffects the peripheral and central nervous system

29 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 1 a) CORRECT Click here to move onto the next question a) CORRECT Click here to move onto the next question Which of the statements are correct with regards to the botulinum toxin? a)Botulinum toxin is one of the most potent neurotoxins known b)Botulism is most commonly caused by the Botulinum neurotoxins A and C c)Causes inhibition of the action of GABA d)Affects the peripheral and central nervous system Which of the statements are correct with regards to the botulinum toxin? a)Botulinum toxin is one of the most potent neurotoxins known b)Botulism is most commonly caused by the Botulinum neurotoxins A and C c)Causes inhibition of the action of GABA d)Affects the peripheral and central nervous system

30 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 1 b) INCORRECT Botulism is caused by the neurotoxins A-G. A, B and E are the most common cause of disease in humans. Please choose another option b) INCORRECT Botulism is caused by the neurotoxins A-G. A, B and E are the most common cause of disease in humans. Please choose another option Which of the statements are correct with regards to the botulinum toxin? a)Botulinum toxin is one of the most potent neurotoxins knownBotulinum toxin is one of the most potent neurotoxins known b)Botulism is most commonly caused by the Botulinum neurotoxins A and CBotulism is most commonly caused by the Botulinum neurotoxins A and C c)Causes inhibition of the action of GABACauses inhibition of the action of GABA d)Affects the peripheral and central nervous systemAffects the peripheral and central nervous system Which of the statements are correct with regards to the botulinum toxin? a)Botulinum toxin is one of the most potent neurotoxins knownBotulinum toxin is one of the most potent neurotoxins known b)Botulism is most commonly caused by the Botulinum neurotoxins A and CBotulism is most commonly caused by the Botulinum neurotoxins A and C c)Causes inhibition of the action of GABACauses inhibition of the action of GABA d)Affects the peripheral and central nervous systemAffects the peripheral and central nervous system

31 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 1 c) INCORRECT Botulinum toxin causes inhibition of release of acetylcholine at the neuromuscular junction. Tetanus toxin causes blockage of the action of GABA.. Please choose another option c) INCORRECT Botulinum toxin causes inhibition of release of acetylcholine at the neuromuscular junction. Tetanus toxin causes blockage of the action of GABA.. Please choose another option Which of the statements are correct with regards to the botulinum toxin? a)Botulinum toxin is one of the most potent neurotoxins knownBotulinum toxin is one of the most potent neurotoxins known b)Botulism is most commonly caused by the Botulinum neurotoxins A and CBotulism is most commonly caused by the Botulinum neurotoxins A and C c)Causes inhibition of the action of GABACauses inhibition of the action of GABA d)Affects the peripheral and central nervous systemAffects the peripheral and central nervous system Which of the statements are correct with regards to the botulinum toxin? a)Botulinum toxin is one of the most potent neurotoxins knownBotulinum toxin is one of the most potent neurotoxins known b)Botulism is most commonly caused by the Botulinum neurotoxins A and CBotulism is most commonly caused by the Botulinum neurotoxins A and C c)Causes inhibition of the action of GABACauses inhibition of the action of GABA d)Affects the peripheral and central nervous systemAffects the peripheral and central nervous system

32 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 1 d) INCORRECT Incorrect. Botulism causes PNS involvement only. The toxin does not affect the CNS. Please choose another option d) INCORRECT Incorrect. Botulism causes PNS involvement only. The toxin does not affect the CNS. Please choose another option Which of the statements are correct with regards to the botulinum toxin? a)Botulinum toxin is one of the most potent neurotoxins knownBotulinum toxin is one of the most potent neurotoxins known b)Botulism is most commonly caused by the Botulinum neurotoxins A and CBotulism is most commonly caused by the Botulinum neurotoxins A and C c)Causes inhibition of the action of GABACauses inhibition of the action of GABA d)Affects the peripheral and central nervous systemAffects the peripheral and central nervous system Which of the statements are correct with regards to the botulinum toxin? a)Botulinum toxin is one of the most potent neurotoxins knownBotulinum toxin is one of the most potent neurotoxins known b)Botulism is most commonly caused by the Botulinum neurotoxins A and CBotulism is most commonly caused by the Botulinum neurotoxins A and C c)Causes inhibition of the action of GABACauses inhibition of the action of GABA d)Affects the peripheral and central nervous systemAffects the peripheral and central nervous system

33 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 2 With regards to botulism…. a)Food borne botulism is caused by ingestion of clostridium botulinum in contaminated food True False With regards to botulism…. a)Food borne botulism is caused by ingestion of clostridium botulinum in contaminated food True False

34 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 2 a)Food borne botulism is caused by ingestion of clostridium botulinum in contaminated food True False a)Food borne botulism is caused by ingestion of clostridium botulinum in contaminated food True False TRUE- INCORRECT Food borne botulism is caused by ingestion of pre formed toxin. Click here to move onto the next question TRUE- INCORRECT Food borne botulism is caused by ingestion of pre formed toxin. Click here to move onto the next question

35 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 2 a)Food borne botulism is caused by ingestion of clostridium botulinum in contaminated food True False a)Food borne botulism is caused by ingestion of clostridium botulinum in contaminated food True False FALSE- CORRECT Food borne botulism is caused by ingestion of pre formed toxin. Click here to move onto the next question FALSE- CORRECT Food borne botulism is caused by ingestion of pre formed toxin. Click here to move onto the next question

36 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 2 b) Wound botulism is caused by contamination of a wound with the spores of clostridium botulinum True False b) Wound botulism is caused by contamination of a wound with the spores of clostridium botulinum True False

37 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 2 b) Wound botulism is caused by contamination of a wound with the spores of clostridium botulinum True False b) Wound botulism is caused by contamination of a wound with the spores of clostridium botulinum True False TRUE- INCORRECT Wound botulism is cause by contimination with clostridium botulinum and then production of toxin in vivo. Click here to move onto the next question TRUE- INCORRECT Wound botulism is cause by contimination with clostridium botulinum and then production of toxin in vivo. Click here to move onto the next question

38 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 2 b) Wound botulism is caused by contamination of a wound with the spores of clostridium botulinum True False b) Wound botulism is caused by contamination of a wound with the spores of clostridium botulinum True False FALSE- CORRECT Wound botulism is cause by contimination with clostridium botulinum and then production of toxin in vivo. Click here to move onto the next question FALSE- CORRECT Wound botulism is cause by contimination with clostridium botulinum and then production of toxin in vivo. Click here to move onto the next question

39 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 2 c) Botulism can be caused by overuse of botox in cosmetic surgery True False c) Botulism can be caused by overuse of botox in cosmetic surgery True False

40 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 2 c) Botulism can be caused by overuse of botox in cosmetic surgery True False c) Botulism can be caused by overuse of botox in cosmetic surgery True False TRUE- CORRECT Rare cases of clinical botulism have been reported in people using excess botox in cosmetic surgery. Click here to move onto the next question TRUE- CORRECT Rare cases of clinical botulism have been reported in people using excess botox in cosmetic surgery. Click here to move onto the next question

41 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 2 c) Botulism can be caused by overuse of botox in cosmetic surgery True False c) Botulism can be caused by overuse of botox in cosmetic surgery True False FALSE- INCORRECT Rare cases of clinical botulism have been reported in people using excess botox in cosmetic surgery. Click here to move onto the next question FALSE- INCORRECT Rare cases of clinical botulism have been reported in people using excess botox in cosmetic surgery. Click here to move onto the next question

42 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 2 d) Infantile botulism is caused by colonisation of the GI tract with clostridium botulinum True False d) Infantile botulism is caused by colonisation of the GI tract with clostridium botulinum True False

43 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 2 d) Infantile botulism is caused by colonisation of the GI tract with clostridium botulinum True False d) Infantile botulism is caused by colonisation of the GI tract with clostridium botulinum True False TRUE- CORRECT Infantile botulism is caused by colonisation of the GI tract with clostridium botulinum and production of toxin in vivo. Click here to move onto the next question TRUE- CORRECT Infantile botulism is caused by colonisation of the GI tract with clostridium botulinum and production of toxin in vivo. Click here to move onto the next question

44 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 2 d) Infantile botulism is caused by colonisation of the GI tract with clostridium botulinum True False d) Infantile botulism is caused by colonisation of the GI tract with clostridium botulinum True False FALSE- INCORRECT Infantile botulism is caused by colonisation of the GI tract with clostridium botulinum and production of toxin in vivo. Click here to move onto the next question FALSE- INCORRECT Infantile botulism is caused by colonisation of the GI tract with clostridium botulinum and production of toxin in vivo. Click here to move onto the next question

45 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 2 e) Wound botulism is seen in intravenous drug users True False e) Wound botulism is seen in intravenous drug users True False

46 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 2 e) Wound botulism is seen in intravenous drug users True False e) Wound botulism is seen in intravenous drug users True False TRUE- INCORRECT Wound botulism is seen in "skin poppers" where necrotic tissue allows spores in contaminated heroin to germinate. Click here to move onto the next question TRUE- INCORRECT Wound botulism is seen in "skin poppers" where necrotic tissue allows spores in contaminated heroin to germinate. Click here to move onto the next question

47 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 2 e) Wound botulism is seen in intravenous drug users True False e) Wound botulism is seen in intravenous drug users True False FALSE- CORRECT Wound botulism is seen in "skin poppers" where necrotic tissue allows spores in contaminated heroin to germinate. Click here to move onto the next question FALSE- CORRECT Wound botulism is seen in "skin poppers" where necrotic tissue allows spores in contaminated heroin to germinate. Click here to move onto the next question

48 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 3 Which of the following are cardinal features of acute botulism infection? a)Ascending flaccid paralysis True False Which of the following are cardinal features of acute botulism infection? a)Ascending flaccid paralysis True False

49 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 3 Which of the following are cardinal features of acute botulism infection? a)Ascending flaccid paralysis True False Which of the following are cardinal features of acute botulism infection? a)Ascending flaccid paralysis True False TRUE- INCORRECT Descending flaccid paralysis Click here to move onto the next question TRUE- INCORRECT Descending flaccid paralysis Click here to move onto the next question

50 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 3 Which of the following are cardinal features of acute botulism infection? a)Ascending flaccid paralysis True False Which of the following are cardinal features of acute botulism infection? a)Ascending flaccid paralysis True False FALSE- CORRECT Descending flaccid paralysis Click here to move onto the next question FALSE- CORRECT Descending flaccid paralysis Click here to move onto the next question

51 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 3 Which of the following are cardinal features of acute botulism infection? b) Bilateral cranial nerve palsies True False Which of the following are cardinal features of acute botulism infection? b) Bilateral cranial nerve palsies True False

52 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 3 Which of the following are cardinal features of acute botulism infection? b) Bilateral cranial nerve palsies True False Which of the following are cardinal features of acute botulism infection? b) Bilateral cranial nerve palsies True False TRUE- CORRECT Click here to move onto the next question TRUE- CORRECT Click here to move onto the next question

53 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 3 Which of the following are cardinal features of acute botulism infection? b) Bilateral cranial nerve palsies True False Which of the following are cardinal features of acute botulism infection? b) Bilateral cranial nerve palsies True False FALSE- INCORRECT Click here to move onto the next question FALSE- INCORRECT Click here to move onto the next question

54 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 3 Which of the following are cardinal features of acute botulism infection? c) Fever True False Which of the following are cardinal features of acute botulism infection? c) Fever True False

55 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 3 Which of the following are cardinal features of acute botulism infection? c) Fever True False Which of the following are cardinal features of acute botulism infection? c) Fever True False TRUE- INCORRECT Botulism is caused by the action of a neurotoxin and fever is NOT a feature. Click here to move onto the next question TRUE- INCORRECT Botulism is caused by the action of a neurotoxin and fever is NOT a feature. Click here to move onto the next question

56 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 3 Which of the following are cardinal features of acute botulism infection? c) Fever True False Which of the following are cardinal features of acute botulism infection? c) Fever True False FALSE- CORRECT Botulism is caused by the action of a neurotoxin and fever is NOT a feature. Click here to move onto the next question FALSE- CORRECT Botulism is caused by the action of a neurotoxin and fever is NOT a feature. Click here to move onto the next question

57 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 3 Which of the following are cardinal features of acute botulism infection? d) Dry mouth True False Which of the following are cardinal features of acute botulism infection? d) Dry mouth True False

58 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 3 Which of the following are cardinal features of acute botulism infection? d) Dry mouth True False Which of the following are cardinal features of acute botulism infection? d) Dry mouth True False TRUE- CORRECT Click here to move onto the next question TRUE- CORRECT Click here to move onto the next question

59 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 3 Which of the following are cardinal features of acute botulism infection? d) Dry mouth True False Which of the following are cardinal features of acute botulism infection? d) Dry mouth True False FALSE- INCORRECT Click here to move on to the next question FALSE- INCORRECT Click here to move on to the next question

60 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 3 Which of the following are cardinal features of acute botulism infection? e)Respiratory failure True False Which of the following are cardinal features of acute botulism infection? e)Respiratory failure True False

61 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 3 Which of the following are cardinal features of acute botulism infection? e)Respiratory failure True False Which of the following are cardinal features of acute botulism infection? e)Respiratory failure True False TRUE- CORRECT Click here to move onto the next question TRUE- CORRECT Click here to move onto the next question

62 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 3 Which of the following are cardinal features of acute botulism infection? e)Respiratory failure True False Which of the following are cardinal features of acute botulism infection? e)Respiratory failure True False FALSE- INCORRECT Click here to move on to the next question FALSE- INCORRECT Click here to move on to the next question

63 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 3 Which of the following are cardinal features of acute botulism infection? f) Confusion True False Which of the following are cardinal features of acute botulism infection? f) Confusion True False

64 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 3 Which of the following are cardinal features of acute botulism infection? f) Confusion True False Which of the following are cardinal features of acute botulism infection? f) Confusion True False TRUE- INCORRECT The botulinum toxin does not cross into or involve the central nervous system. Click here to move onto the next question TRUE- INCORRECT The botulinum toxin does not cross into or involve the central nervous system. Click here to move onto the next question

65 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 3 Which of the following are cardinal features of acute botulism infection? f) Confusion True False Which of the following are cardinal features of acute botulism infection? f) Confusion True False FALSE- CORRECT The botulinum toxin does not cross into or involve the central nervous system. Click here to move onto the next question FALSE- CORRECT The botulinum toxin does not cross into or involve the central nervous system. Click here to move onto the next question

66 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 4 Which of the following are correct regarding the diagnosis of botulism? a)Demonstration of the toxin in serum is found in 60-70% of cases of wound botulism True False Which of the following are correct regarding the diagnosis of botulism? a)Demonstration of the toxin in serum is found in 60-70% of cases of wound botulism True False

67 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 4 Which of the following are correct regarding the diagnosis of botulism? a)Demonstration of the toxin in serum is found in 60-70% of cases of wound botulism True False Which of the following are correct regarding the diagnosis of botulism? a)Demonstration of the toxin in serum is found in 60-70% of cases of wound botulism True False TRUE- INCORRECT Circulating toxin is found in approximately 40% of cases of wound botulism. Click here to move onto the next question TRUE- INCORRECT Circulating toxin is found in approximately 40% of cases of wound botulism. Click here to move onto the next question

68 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 4 Which of the following are correct regarding the diagnosis of botulism? a)Demonstration of the toxin in serum is found in 60-70% of cases of wound botulism True False Which of the following are correct regarding the diagnosis of botulism? a)Demonstration of the toxin in serum is found in 60-70% of cases of wound botulism True False FALSE- CORRECT Circulating toxin is found in approximately 40% of cases of wound botulism. Click here to move onto the next question FALSE- CORRECT Circulating toxin is found in approximately 40% of cases of wound botulism. Click here to move onto the next question

69 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 4 Which of the following are correct regarding the diagnosis of botulism? b) The botulism toxin can be isolated in faecal samples in 70% of patients within two days of onset of symptoms True False Which of the following are correct regarding the diagnosis of botulism? b) The botulism toxin can be isolated in faecal samples in 70% of patients within two days of onset of symptoms True False

70 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 4 Which of the following are correct regarding the diagnosis of botulism? b) The botulism toxin can be isolated in faecal samples in 70% of patients within two days of onset of symptoms True False Which of the following are correct regarding the diagnosis of botulism? b) The botulism toxin can be isolated in faecal samples in 70% of patients within two days of onset of symptoms True False TRUE- CORRECT Click here to move onto the next question TRUE- CORRECT Click here to move onto the next question

71 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 4 Which of the following are correct regarding the diagnosis of botulism? b) The botulism toxin can be isolated in faecal samples in 70% of patients within two days of onset of symptoms True False Which of the following are correct regarding the diagnosis of botulism? b) The botulism toxin can be isolated in faecal samples in 70% of patients within two days of onset of symptoms True False FALSE- INCORRECT Click here to move on to the next question FALSE- INCORRECT Click here to move on to the next question

72 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 4 Which of the following are correct regarding the diagnosis of botulism? c)Presence of the toxin is needed to confirm the diagnosis of botulism True False Which of the following are correct regarding the diagnosis of botulism? c)Presence of the toxin is needed to confirm the diagnosis of botulism True False

73 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 4 Which of the following are correct regarding the diagnosis of botulism? c)Presence of the toxin is needed to confirm the diagnosis of botulism True False Which of the following are correct regarding the diagnosis of botulism? c)Presence of the toxin is needed to confirm the diagnosis of botulism True False TRUE- INCORRECT Botulism is a clinical diagnosis. The presence of the toxin can help to confirm this. Click here to move onto the next question TRUE- INCORRECT Botulism is a clinical diagnosis. The presence of the toxin can help to confirm this. Click here to move onto the next question

74 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 4 Which of the following are correct regarding the diagnosis of botulism? c)Presence of the toxin is needed to confirm the diagnosis of botulism True False Which of the following are correct regarding the diagnosis of botulism? c)Presence of the toxin is needed to confirm the diagnosis of botulism True False FALSE- CORRECT Botulism is a clinical diagnosis. The presence of the toxin can help to confirm this. Click here to move onto the next question FALSE- CORRECT Botulism is a clinical diagnosis. The presence of the toxin can help to confirm this. Click here to move onto the next question

75 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 4 Which of the following are correct regarding the diagnosis of botulism? d) Toxin levels are measured by bioassay in mice True False Which of the following are correct regarding the diagnosis of botulism? d) Toxin levels are measured by bioassay in mice True False

76 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 4 Which of the following are correct regarding the diagnosis of botulism? d) Toxin levels are measured by bioassay in mice True False Which of the following are correct regarding the diagnosis of botulism? d) Toxin levels are measured by bioassay in mice True False TRUE- CORRECT Click here to move onto the next question TRUE- CORRECT Click here to move onto the next question

77 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 4 Which of the following are correct regarding the diagnosis of botulism? d) Toxin levels are measured by bioassay in mice True False Which of the following are correct regarding the diagnosis of botulism? d) Toxin levels are measured by bioassay in mice True False FALSE- INCORRECT Click here to move on to the next question FALSE- INCORRECT Click here to move on to the next question

78 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 4 Which of the following are correct regarding the diagnosis of botulism? e) Serum toxin levels are unhelpful in infantile botulism True False Which of the following are correct regarding the diagnosis of botulism? e) Serum toxin levels are unhelpful in infantile botulism True False

79 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 4 Which of the following are correct regarding the diagnosis of botulism? e) Serum toxin levels are unhelpful in infantile botulism True False Which of the following are correct regarding the diagnosis of botulism? e) Serum toxin levels are unhelpful in infantile botulism True False TRUE- CORRECT Click here to finish the session TRUE- CORRECT Click here to finish the session

80 B OTULISM Learning Objectives Overview Microbiology Transmission Types of Botulism Actions of the toxin Clinical features Differential diagnosisDifferential diagnosis Investigations Treatment Key points Summary References and further readingReferences and further reading Questions Question 4 Which of the following are correct regarding the diagnosis of botulism? e) Serum toxin levels are unhelpful in infantile botulism True False Which of the following are correct regarding the diagnosis of botulism? e) Serum toxin levels are unhelpful in infantile botulism True False FALSE- INCORRECT Click here to finish the session FALSE- INCORRECT Click here to finish the session

81 Congratulations on completing this module and thank you for using NeuroID: elearning. We hope to see you at a NeuroID: Liverpool Neurological Infectious Diseases Course soon. Download a certificateDownload a certificate, and then to finish the module CLICK HERE.CLICK HERE

82 Liverpool Medical Institution, UK Provisional date: May 2013 NeuroID 2013: Liverpool Neurological Infectious Diseases Course Ever struggled with a patient with meningitis or encephalitis, and not known quite what to do? Then the Liverpool Neurological infectious Diseases Course is for you! For Trainees and Consultants in Adult and Paediatric Neurology, Infectious Diseases, Acute Medicine, Emergency Medicine and Medical Microbiology who want to update their knowledge, and improve their skills. For more information and to REGISTER NOW VISIT: Presented by Leaders in the Field Commonly Encountered Clinical Problems Practical Management Approaches Rarities for Reference Interactive Case Presentations State of the Art Updates Pitfalls to Avoid Controversies in Neurological Infections To learn more about neurological infectious diseases… Convenors: Prof Tom Solomon, Dr Enitan Carrol, Dr Rachel Kneen, Dr Nick Beeching, Dr Benedict Michael Feedback from previous course: “Would unreservedly recommend to others” “An excellent 2 days!! The best course for a long time”


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