Clostridium botulinum Dr.T.V.Rao MD

Clostridium botulinum Clostridium botulinum is a Gram-positive, rod- shaped bacterium that produces several toxins. The best known are its neurotoxins, subdivided in types A-G, that cause the flaccid muscular paralysis seen in botulism. They are also the main paralytic agent in botox. C. botulinum is an anaerobic spore-former, which produces oval, sub terminal endospores and is commonly found in soil.

Characters of C.botulinum A gram-positive, anaerobic bacilli. Spore forming. Toxin forming. Heat sensitive. Prefers low acid environment. Cause Botulism disease.

Botulism- Microbiology Toxin produced by the bacterium Clostridium botulinum Anaerobic, gram positive, rod- shaped bacteria Bacteria are 0.5 to 2.0 mcm in width and 1.6 to 22.0 mcm in length Create spores that can remain dormant for 30 years or more Spores extremely resistant to environmental stressors, such as heat and UV light C. botulinum

Microbiology C. Botulinum – Gram-positive obligate anaerobic bacillus – Spore-forming – Produces botulinum toxin – Heat sensitive as bacillus – Prefers low acid environment Inglesby, T. The Washington Post Wednesday, December 9, 1998; Page H01

Toxins liberated during growth. Seven types of toxins (A-G). Antigenic (light and heavy chain). Environmental survival. (Inactivated by heat 100ºC for 20min ). Most potential biological warfare agents. Lethal dose= 1-2  g.

Neurotoxin types Neurotoxin types production is the unifying feature of the species C. botulinum. Seven types of toxins have been identified and allocated a letter (A-G). Most strains produce one type of neurotoxin but strains producing multiple toxins have been described. The toxin type has been designated Bf as the type B toxin was found in excess to the type F. Similarly, strains producing Ab and Af toxins have been reported. There is evidence that the neurotoxin genes have been the subject of horizontal gene transfer, possibly from a viral source. This theory is supported by the presence of integration sites flanking the toxin in some strains of C. botulinum. However, these integrations sites are degraded indicating that the C. botulinum acquired the toxin genes quite far into the evolutionary past. ( Wikipedia )

Toxins Botulinum toxin is synthesized as a single polypeptide chain ( low potency). The toxin is nicked by a bacterial protease (or by gastric proteases) to produce two chains :  a light chain (the A fragment)  a heavy chain (the B fragment) connected by a disulfide bond. The A fragment of the nicked toxin, becomes the most potent toxin found in nature

Toxins Absorbed in GIT, blood, peripheral neuromuscular synapse. Presynaptic block Acetylcholine release (by proteolysis of SNARE proteins in neuron which is important in Ach release) muscle paralysis. SNARE proteins are synaptobrevin, SNAP-25 and syntaxin.

Pathogenesis Transmitted in three ways: – Food or water toxin contamination. – Wound infected with C. Botulinum. – Ingestion of C. botulinum. Most common contaminated food: Vacuum packed, or canned alkaline food. E.g. fish, green beans, any home-canned food. Foods eaten without cooking.

Pathogenesis of Infant Botulism Cause :infection by C. botulinum. Age: weeks of age. Characterized by constipation and weak sucking. sudden infant death syndrome-SIDS It cause “sudden infant death syndrome-SIDS”. found in the stool.

Pathogenesis Toxin must enter body – Direct toxin absorption from mucosal surface Gut – foodborne Lungs – inhalational – Via toxin produced by infection with C.botulinum Skin breaks – wound botulism after trauma, IV drugs Gut – intestinal botulism Would not be seen in BT event, as toxin would be used Does not penetrate intact skin

Pathogenesis Estimated lethal human dose crystalline type A toxin  g given iv or im  g inhalationally 70  g given po

Symptoms Appear in hrs. include : Blurry vision, Double vision. Dry mouth. Trouble swallowing. Trouble breathing. Muscle weakness. Fever is not a symptom of botulism

Clinical Features Classic Triad – Symmetric, descending flaccid paralysis with prominent bulbar palsies – Afebrile – Clear sensorium Bulbar palsies summarized as "4 Ds" – Diplopia, dysarthria, dysphonia, dysphagia

Botulism symptoms: Characteristic Triad Symmetric, descending (cranial nerves first, then upper extremities, then respiratory muscles, and lower extremities) flaccid paralysis with prominent bulbar palsies, particularly: – Diplopia – double vision – Dysarthria – difficulty in speech articulation – Dysphonia – difficulty in voice production – Dysphagia – difficulty in swallowing Patient is afebrile (although fever may be present in wound botulism) Patient’s sensibilities intact; cognitive functions unaffected

Signs of Food-borne and Wound Botulism Ventilatory (respiratory) problems Eye muscle paresis/paralysis (extra ocular, eyelid) Dry mucous membranes in mouth/throat Dilated, fixed pupils Ataxia Hypotension Nystagmus Decreased to absent deep tendon reflexes A. Patient at rest. Note bilateral mild ptosis, dilated pupils, disconjugate gaze, and symmetric facial muscles. B, Patient was requested to perform his maximum smile. Note absent smile creases, ptosis, minimally asymmetric smile.

Diagnostic laboratory test Toxins found in serum, leftover food. Mice injected with toxin die rapidly. In infants, found in stool. Brain scan, spinal fluid examination, nerve conduction test.

Diagnosis Clinical diagnosis Diagnostic tests help confirm – Toxin neutralization mouse bioassay Serum, stool, or suspect foods – Infant botulism C botulinum organism or toxin in feces Testing is done in Reference laboratories under Biosafety regulations

Treatment Trivalent (A,B,E) antitoxin must administrated intravenously (recovery takes several weeks) Mechanical respirator is administrated if necessary.

Treatment Antitoxin action – Food-borne botulism Neutralizing antibody levels exceed toxin levels Single dose adequate – Large exposure (e.g. biological weapon) can confirm adequacy of neutralization – recheck toxin levels after treatment Antitoxin adverse effects – Serum sickness (2-9%), anaphylaxis (2%)

Prevention Natural disease – Boil home-canned foods 10 minutes – Follow USDA instructions on home- canning – Restrict honey from < 1 year old – Seek medical care for wounds – Avoid injectable street drugs

Programme Created by Dr.T.V.Rao MD for Medical and Health Care Professionals in the Developing World Dr.T.V.Rao MD25

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