Botulism in Italy, 1986 to 2015

Approaching toxigenic Clostridia from a One Health perspective

Spore-forming pathogens have a unique capacity to thrive in diverse environments, and with temporal persistence afforded through their ability to sporulate. Their prevalence in diverse ecosystems requires a One Health approach to identify critical reservoirs and outbreak-associated transmission chains, given their capacity to freely move across soils, waterways, foodstuffs and as commensals or infecting pathogens in human and animal populations. Among anaerobic spore-formers, genomic resources for pathogens including C. botulinum, C. difficile, and C. perfringens enable our capacity to identify common and unique factors that support their persistence in diverse reservoirs and capacity to cause disease. Publicly available genomic resources for spore-forming pathogens at NCBI's Pathogen Detection program aid outbreak investigations and longitudinal monitoring in national and international programs in public health and food safety, as well as for local healthcare systems. These tools also enable research to derive new knowledge regarding disease pathogenesis, and to inform strategies in disease prevention and treatment. As global community resources, the continued sharing of strain genomic data and phenotypes further enhances international resources and means to develop impactful applications. We present examples showing use of these resources in surveillance, including capacity to assess linkages among clinical, environmental, and foodborne reservoirs and to further research investigations into factors promoting their persistence and virulence in different settings.

Botulism Cases in Romania-An Overview of 14-Year National Surveillance Data

Botulism is a priority disease worldwide because it has a very severe course of evolution that can lead to death. This paper aims to describe the main epidemiological characteristics of botulism cases confirmed in Romania over 14 years (2007-2020). We performed a retrospective study using the publicly available national surveillance data and reported to the National Institute of Public Health. A total of 325 cases of foodborne botulism were reported in Romania, with no infant or wound botulism. Most of the cases (125, 38.5%) were reported among young adults (25-44 years old), over half (205, 63%) of them living in rural areas. The incriminated food item was identified in 161 cases; in most cases (145, 90%) the food item was prepared in the household. The main food category was represented by meat and meat-based products (94, 68.6%). In almost all cases the identified type was BoNT/B (230/231, 99.5%). Fifteen deaths were recorded, and the case fatality rate was 4.6%. Botulism cases were reported annually in Romania. Surveillance data are essential for implementing control measures and adapting educational campaigns according to existing needs.

Clinicopathological insights into an outbreak of foodborne botulism in Hamadan, Iran, in 2023: A microbiological and laboratory findings

Background and Objective

Foodborne botulism is one of the potentially fatal forms of food poisoning, usually caused by ingestion of home-canned vegetables, fruits, and dairy and fish products. This study aimed to assess the frequency of signs and symptoms in patients with botulism following the ingestion of homemade Doogh, a traditional milk-based beverage, in Hamadan, Iran in 2023. We also examined the general characteristics of the recruited patients.

Methods

During an outbreak, 21 patients were referred to the hospital because of food poisoning. All patients had a history of consumption of Doogh. After careful physical examination, all of them were hospitalized. Botulism was suspected in all patients except for the first patient.

Results

The mean age of admitted patients was 33.09 ± 18.44 years, with 23.80% being males and 76.20% females. Incubation period in our patients was 68 ± 28.48 h. Notable symptoms included diplopia (95.23%), nausea and vomiting (85.71%), blurred vision (80.95%), and dizziness (61.90%). The laboratory results were within the normal range. No deaths occurred in this patient cohort. Furthermore, botulinum spores were detected in Doogh samples collected from the outbreak, confirming the presence of Clostridium botulinum spores as a source of the outbreak.

Conclusions

This study highlights that the initial manifestations of botulism predominantly involved ophthalmologic abnormalities in most patients. Additionally, symptoms such as nausea, vomiting, and dizziness may manifest in cases of foodborne botulism. Timely diagnosis and treatment of botulism following the consumption of homemade Doogh played a crucial role in achieving positive outcomes, with no fatalities recorded in this patient cohort.

[Clinical and neuroelectrophysiological features of botulism in children: an analysis of eight sporadic cases]

OBJECTIVES

To study the clinical and neuroelectrophysiological features of botulism in children.

METHODS

A retrospective analysis was conducted on the clinical data of eight children who were diagnosed with botulism in the Department of Neurology, Hunan Children's Hospital, from August 2015 to October 2022.

RESULTS

All eight children were found to have symmetrical cranial nerve palsy and flaccid paralysis of the extremities, with a descending pattern. Seven children presented with respiratory muscle paralysis. Electrophysiological examinations revealed decreased compound muscle action potential (CMAP) amplitudes in 5 children, increased CMAP amplitudes exceeding 40.0% in 6 children during high-frequency repetitive nerve stimulation, and short duration, low amplitude, and polyphasic motor unit action potentials in 4 children.

CONCLUSIONS

The main clinical features of botulism in children include symmetric, descending flaccid paralysis starting from cranial nerves, with the possibility of respiratory muscle paralysis. Electrophysiological abnormalities associated with it include decreased CMAP amplitudes, increased CMAP amplitudes during high-frequency repetitive nerve stimulation, and short duration, low amplitude, and polyphasic motor unit action potentials.

Foodborne Botulism, Canada, 2006-20211

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

Dual-Toxin ("Bivalent") Infant Botulism in California, 1976-2020: Epidemiologic, Clinical, and Laboratory Aspects

OBJECTIVE

To assess the consequences of infant botulism that result from Clostridium botulinum strains that produce 2 botulinum toxin serotypes, termed "bivalent."

STUDY DESIGN

Epidemiologic investigations used a standard questionnaire. Clostridium botulinum strains were isolated by standard methods. Botulinum neurotoxin (BoNT) serotypes and the relative amounts of toxins produced were identified using the standard mouse bioassay. BoNT subtypes and genomic locations were identified by DNA nucleotide sequencing.

RESULTS

Thirty bivalent cases of infant botulism occurred in the 45 years (1976-2020), representing 2.0% of all California infant botulism cases, in the 3 geographic regions of southern California, the southern Central Valley, and mid-northern California. Toxin serotype combinations were Ba (n = 22), Bf (n = 7), and Ab (n = 1). More patients with illness caused by bivalent C botulinum Ba and Bf strains needed endotracheal intubation at hospital admission, 60.0% (18/30), than did patients with illness caused by monovalent BoNT/B strains, 34.3% (152/443). The Cbotulinum Ba and Bf strains produced BoNT/B5 and either BoNT/A4 or /F2. The Ab strain produced BoNT/A2 and /B1. All toxin gene clusters were on plasmids.

CONCLUSIONS

Infant botulism caused by bivalent Cbotulinum strains occurs sporadically and in diverse locations in California. Affected patients with bivalent Ba and Bf strains lacked distinguishing epidemiological features but appeared to be more severely paralyzed at hospital presentation than patients with illness caused by only BoNT/B. These bivalent strains produced BoNT subtypes A2, A4, B1, B5, and F2, and all toxin gene clusters were on plasmids.

First cross-border outbreak of foodborne botulism in the European Union associated with the consumption of commercial dried roach (Rutilus rutilus)

Botulism outbreaks due to commercial products are extremely rare in the European Union. Here we report on the first international outbreak of foodborne botulism caused by commercial salt-cured, dried roach (Rutilus rutilus). Between November and December 2016, an outbreak of six foodborne botulism type E cases from five unrelated households was documented in Germany and Spain. The outbreak involved persons of Russian and Kazakh backgrounds, all consumed unheated salt-cured, dried roach-a snack particularly favored in Easter-European countries. The implicated food batches had been distributed by an international wholesaler and were recalled from Europe-wide outlets of a supermarket chain and other independent retailers. Of interest, and very unlike to other foodborne disease outbreaks which usually involves a single strain or virus variant, different Clostridium botulinum strains and toxin variants could be identified even from a single patient's sample. Foodborne botulism is a rare but potentially life-threatening disease and almost exclusively involves home-made or artisan products and thus, outbreaks are limited to individual or few cases. As a consequence, international outbreaks are the absolute exception and this is the first one within the European Union. Additional cases were likely prevented by a broad product recall, underscoring the importance of timely public health action. Challenges and difficulties on the diagnostic and epidemiological level encountered in the outbreak are highlighted.

Botulism in Spain: Epidemiology and Outcomes of Antitoxin Treatment, 1997-2019

BACKGROUND

Botulism is a low incidence but potentially fatal infectious disease caused by neurotoxins produced mainly by Clostridium botulinum. There are different routes of acquisition, food-borne and infant/intestinal being the most frequent presentation, and antitoxin is the treatment of choice in all cases. In Spain, botulism is under surveillance, and case reporting is mandatory.

METHODS

This retrospective study attempts to provide a more complete picture of the epidemiology of botulism in Spain from 1997 to 2019 and an assessment of the treatment, including the relationship between a delay in antitoxin administration and the length of hospitalization using the Cox proportional hazards test and Kruskal-Wallis test, and an approach to the frequency of adverse events, issues for which no previous national data have been published.

RESULTS

Eight of the 44 outbreaks were associated with contaminated commercial foods involving ≤7 cases/outbreak; preserved vegetables were the main source of infection, followed by fish products; early antitoxin administration significantly reduces the hospital stay, and adverse reactions to the antitoxin affect around 3% of treated cases.

Benign food-borne type B botulism presenting as unilateral internal ophthalmoplegia: a case report

BACKGROUND

Food-borne botulism is a rare neuromuscular junction disorder due to the effect of toxins released from Clostridium botulinum ingested by eating improperly stored food. Its classic manifestation is a rapidly evolving descending symmetrical flaccid paralysis with dysautonomia.

CASE PRESENTATION

We have described a case of type B food-borne botulism with a benign clinical course characterized by an initially unilateral tonic mydriatic pupil. An extensive neurophysiological evaluation inclusive of pilocarpine eye drop(s) test, facial and limbs nerve stimulation and sudomotor tests, was decisively leading the diagnostic process.

CONCLUSIONS

The importance of what has been described here lies in underlining that it is always advisable to consider food-borne botulinum intoxication, even in the case of unilateral/asymmetrical internal ophthalmoplegia without generalized progressive involvement of the voluntary muscles.

Human and animal botulism surveillance in France from 2008 to 2019

Botulism is a human and animal neurological disease caused by the action of bacterial neurotoxins (botulinum toxins) produced by bacteria from the genus Clostridium. This disease induces flaccid paralysis that can result in respiratory paralysis and heart failure. Due to its serious potential impact on public health, botulism is a closely monitored notifiable disease in France through a case-based passive surveillance system. In humans, this disease is rare, with an average of 10 outbreaks reported each year, mainly due to the consumption of contaminated foods. Type B and to a lesser extend type A are responsible for the majority of cases of foodborne botulism. Each year, an average of 30 outbreaks are recorded on poultry farms, about 20 cases in wild birds and about 10 outbreaks in cattle, involving a large number of animals. Mosaic forms C/D and D/C in birds and cattle, respectively, are the predominant types in animals in France. Types C and D have also been observed to a lesser extent in animals. With the exception of botulinum toxin E, which was exceptionally detected throughout the period in wild birds, the types of botulism found in animal outbreaks are different from those identified in human outbreaks over the last ten years in France and no human botulism outbreaks investigated have been linked to animal botulism. In line with the One Health concept, we present the first integrative approach to the routine surveillance of botulism in humans and animals in France.

A Historical Review of Military Medical Strategies for Fighting Infectious Diseases: From Battlefields to Global Health

The environmental conditions generated by war and characterized by poverty, undernutrition, stress, difficult access to safe water and food as well as lack of environmental and personal hygiene favor the spread of many infectious diseases. Epidemic typhus, plague, malaria, cholera, typhoid fever, hepatitis, tetanus, and smallpox have nearly constantly accompanied wars, frequently deeply conditioning the outcome of battles/wars more than weapons and military strategy. At the end of the nineteenth century, with the birth of bacteriology, military medical researchers in Germany, the United Kingdom, and France were active in discovering the etiological agents of some diseases and in developing preventive vaccines. Emil von Behring, Ronald Ross and Charles Laveran, who were or served as military physicians, won the first, the second, and the seventh Nobel Prize for Physiology or Medicine for discovering passive anti-diphtheria/tetanus immunotherapy and for identifying mosquito Anopheline as a malaria vector and plasmodium as its etiological agent, respectively. Meanwhile, Major Walter Reed in the United States of America discovered the mosquito vector of yellow fever, thus paving the way for its prevention by vector control. In this work, the military relevance of some vaccine-preventable and non-vaccine-preventable infectious diseases, as well as of biological weapons, and the military contributions to their control will be described. Currently, the civil-military medical collaboration is getting closer and becoming interdependent, from research and development for the prevention of infectious diseases to disasters and emergencies management, as recently demonstrated in Ebola and Zika outbreaks and the COVID-19 pandemic, even with the high biocontainment aeromedical evacuation, in a sort of global health diplomacy.

Pauci-symptomatic foodborne botulism due to Clostridium botulinum type B with predominant ophthalmologic presentation possibly after consumption of honey

Foodborne botulism, a toxin-mediated illness caused by Clostridium botulinum, is a public health emergency, and rarely reported in France. We report herein the case of two family members (a father and his son) from Franche-Comté, France, presented with ophthalmological symptoms which occurred after non-specific gastro-intestinal symptoms after a trip to Serbia with a recent consumption of artisanal honey, and suggestive of botulism. The suspected intoxication appeared to be caused by a type B strain of C. botulinum, as demonstrated by toxin-neutralization in the lethal mouse bioassay. Regarding the mild-to-moderate form, the patients were treated symptomatically with monitoring, against antitoxins, with no evidence of relapse afterwards. We want to highlight the importance of recognizing clinical ophthalmologic botulism symptoms as unreactive bilateral mydriasis with lack of accommodation to contribute to earlier diagnosis in case of pauci-symptomatic botulism.

Botulism outbreak in a rural Ethiopia: a case series

BACKGROUND

Foodborne botulism, a toxin-mediated illness caused by Clostridium botulinum, is a public health emergency. Types A, B, and E C. botulinum toxins commonly cause human disease. Outbreaks are often associated with homemade and fermented foods. Botulism is rarely reported in Africa and has never been reported in Ethiopia.

CASE PRESENTATION

In March 2015, a cluster of family members from the Wollega, Oromia region, western Ethiopia presented with a symptom constellation suggestive of probable botulism. Clinical examination, epidemiologic investigation, and subsequent laboratory work identified the cause of the outbreak to be accidental ingestion of botulinum toxin in a traditional chili condiment called "Kochi-kocha," cheese, and clarified butter. Ten out of the fourteen family members who consumed the contaminated products had botulism (attack rate 71.4%) and five died (case fatality rate of 50%). Three of the patients were hospitalized, they presented with altered mental status (n = 2), profound neck and truncal weakness (n = 3), and intact extremity strength despite hyporeflexia (n = 3). The remnant food sample showed botulinum toxin type A with mouse bioassay and C. botulinum type A with culture. Blood drawn on day three of illness from 2/3 (66%) cases was positive for botulinum toxin type-A. Additionally, one of these two cases also had C. botulinum type A cultured from a stool specimen. Two of the cases received Botulism antitoxin (BAT).

CONCLUSION

These are the first confirmed cases of botulism in Ethiopia. The disease occurred due to the consumption of commonly consumed homemade foods. Definite diagnoses of botulism cases are challenging, and detailed epidemiologic and laboratory investigations were critical to the identification of this case series. Improved awareness of botulism risk and improved food preparation and storage may prevent future illnesses. The mortality rate of botulism in resource-limited settings remains high. Countries should make a concerted effort to stockpile antitoxin as that is the easiest and quickest intervention after outbreak detection.

Infant Botulism: Checklist for Timely Clinical Diagnosis and New Possible Risk Factors Originated from a Case Report and Literature Review

Infant botulism is a rare and underdiagnosed disease caused by BoNT-producing clostridia that can temporarily colonize the intestinal lumen of infants less than one year of age. The diagnosis may be challenging because of its rareness, especially in patients showing atypical presentations or concomitant coinfections. In this paper, we report the first infant botulism case associated with Cytomegalovirus coinfection and transient hypogammaglobulinemia and discuss the meaning of these associations in terms of risk factors. Intending to help physicians perform the diagnosis, we also propose a practical clinical and diagnostic criteria checklist based on the revision of the literature.

Epidemiology of botulism in the north-western Romania-a 7-year survey

Botulism is a rare, acute, life-threatening neuro-paralysis. The digestive onset may raise diagnostic issues. The objective of our study was to analyze the clinical and epidemiological data of patients diagnosed with botulism and hospitalized in "Gavril Curteanu" Municipal Clinical Hospital (Oradea, Romania). Detection of the Clostridium botulinum neurotoxin (type B) in the laboratories of the National Institute of Medical-Military Research Development "Cantacuzino", Bucharest, Romania (using the mouse bioassays method) confirmed the diagnostics. The statistical analysis was performed using the IBM SPSS software. Forty-eight patients with the diagnosis of foodborne botulism were hospitalized between 2012 and 2018 (36.92% of the total number of cases of botulism reported in Romania). The winter-spring period was the period when most cases were registered (36 patients, p=0.020). Women from rural areas were predominant (but not statistically significant), and the patients' mean age was 39.93±12.59 years. The most common source/cause of botulism was the consumption of homemade ham. The incubation period was 26.68±22.94 h, and 2.25±1.68 days passed from the clinical onset to diagnosis. The results prove that botulism is still a public health issue, especially in areas where homemade products are prepared using inappropriate/unsafe recipes/procedures.

Foodborne Botulism in Western Romania: Ten Years' Experience at a Tertiary Infectious Disease Hospital

OBJECTIVES

The purpose of this study was to analyze epidemiological data concerning foodborne botulism in Western Romania over the last decade. Botulism, the toxin formed by the bacterium Clostridium botulinum, results in a neuroparalytic disorder capable of severe clinical progression that begins in the cranial nerves and progressively descends. Preventing progression to a severe case entails timely diagnosis since curative assets are restricted. Ingesting food containing a preformed toxin (foodborne botulism) is the most typical form.

METHODS

Medical records were retrospectively analyzed from 2010 to 2020 for all food botulism cases. A seroneutralization test was performed with type A, B and E anti-botulinum sera to establish the kind of toxin involved.

RESULTS

Overall, 18 cases of foodborne botulism were admitted to the hospital during this period and confirmed by laboratory analysis. Most of the participants in our study were men (61.1%), and 77.8% of the total lived in rural areas. All the participants showed classic symptoms of botulism, and dysphagia was present in all cases. The trivalent ABE antitoxin was administered by the hospital, and toxin type B was isolated in all patients. The main sources of the toxin were pork, ham and canned pork meat.

CONCLUSIONS

Stronger efforts are needed to foster community awareness of foodborne botulism, particularly in home-preserved food.

Botulinum Neurotoxin-C Detection Using Nanostructured Porous Silicon Interferometer

Botulinum neurotoxins (BoNT) are the most potent toxins, which are produced by Clostridium bacteria and cause the life-threatening disease of botulism in all vertebrates. Specifically, animal botulism represents a serious environmental and economic concern in animal production due to the high mortality rates observed during outbreaks. Despite the availability of vaccines against BoNT, there are still many outbreaks of botulism worldwide. Alternative assays capable of replacing the conventional in vivo assay in terms of rapid and sensitive quantification, and the applicability for on-site analysis, have long been perused. Herein, we present a simple, highly sensitive and label-free optical biosensor for real-time detection of BoNT serotype C using a porous silicon Fabry–Pérot interferometer. A competitive immunoassay coupled to a biochemical cascade reaction was adapted for optical signal amplification. The resulting insoluble precipitates accumulated within the nanostructure changed the reflectivity spectra by alternating the averaged refractive index. The augmented optical performance allowed for a linear response within the range of 10 to 10,000 pg mL−1 while presenting a detection limit of 4.8 pg mL−1. The practical aspect of the developed assay was verified using field BoNT holotoxins to exemplify the potential use of the developed optical approach for rapid bio-diagnosis of BoNT. The specificity and selectivity of the assay were successfully validated using an adjacent holotoxin relevant for farm animals (BoNT serotype D). Overall, this work sets the foundation for implementing a miniaturized interferometer for routine on-site botulism diagnosis, thus significantly reducing the need for animal experimentation and shortening analysis turnaround for early evidence-based therapy.

Botulism during SARS-CoV-2 pandemic: The importance of differential diagnoses

Botulism is a neuroparalytic syndrome caused by a neurotoxin produced by Clostridium botulinum. We describe a patient with neurological symptoms associated with intoxication by Clostridium botulinum and infection by SARSCoV2. This report underlines that it is mandatory, even in case of SARS-CoV-2 positivity, to investigate all the causes of a clinical pattern.

Infant botulism: an underestimated threat

Infant botulism (IB) is defined as a potentially life-threatening neuroparalytic disorder affecting children younger than 12 months. It is caused by ingestion of food or dust contaminated by Clostridium botulinum spores, which germinate in the infant's large bowel and produce botulinum neurotoxin. Although the real impact of IB is likely underestimated worldwide, the USA has the highest number of cases. The limited reporting of IB in many countries is probably due to diagnostic difficulties and nonspecific presentation. The onset is usually heralded by constipation, followed by bulbar palsy, and then by a descending bilateral symmetric paralysis; ultimately, palsy can involve respiratory and diaphragmatic muscles, leading to respiratory failure. The treatment is based on supportive care and specific therapy with Human Botulism Immune Globulin Intravenous (BIG-IV), and should be started as early as possible. The search for new human-like antibody preparations that are both highly effective and well tolerated has led to the creation of a mixture of oligoclonal antibodies that are highly protective and can be produced in large quantities without the use of animals. Ongoing research for future treatment of IB involves the search for new molecular targets to produce a new generation of laboratory-produced antitoxins, and the development of new vaccines with safety and efficacy profiles that can be scaled up for clinical use. This narrative literature review aims to provide a readable synthesis of the best current literature on microbiological, epidemiological and clinical features of IB, and a practical guide for its treatment.

Foodborne botulism presenting as small bowel obstruction: a case report

BACKGROUND

Small bowel obstruction is one of the leading reasons for accessing to the Emergency Department. Food poisoning from Clostridium botulinum has emerged as a very rare potential cause of small bowel obstruction. The relevance of this case report regards the subtle onset of pathognomonic neurological symptoms, which can delay diagnosis and subsequent life-saving treatment.

CASE PRESENTATION

A 24-year-old man came to our Emergency Department complaining of abdominal pain, fever and sporadic self-limiting episodes of diplopia, starting 4 days earlier. Clinical presentation and radiological imaging suggested a case of small bowel obstruction. Non-operative management was adopted, which was followed by worsening of neurological signs. On specifically questioning the patient, we discovered that his parents had experienced similar, but milder symptoms. The patient also recalled eating home-made preserves some days earlier. A clinical diagnosis of foodborne botulism was established and antitoxin was promptly administered with rapid clinical resolution.

CONCLUSIONS

Though very rare, botulism can mimic small bowel obstruction, and could be associated with a rapid clinical deterioration if misdiagnosed. An accurate family history, frequent clinical reassessments and involvement of different specialists can guide to identify this unexpected diagnosis.

Foodborne Botulism in Ukraine from 1955 to 2018

We aim to identify possible biological, social, and economic factors that could influence the prevalence of foodborne botulism (FB). The objective of this article is to assess epidemiological peculiarities of FB in Ukraine from 1955 to 2018 using national epidemiological surveillance data. This article presents an epidemiological descriptive population-based study of the epidemiology of FB using correlation analysis. From 1955 to 2018, 8614 cases of botulism were recorded in Ukraine causing 659 deaths. The distribution of types of botulism toxins is represented by type A (7.97%), B (59.64%), suspected as C (0.56%), E (25.47%), others (5.33%), and unidentified (1.04%). From 1990 to 2015, the rate correlation between Human Development Index (HDI) and incidence of botulism was −0.75 ± 0.20. Homemade canned meat and fish continue to be the leading causes of botulism in Ukraine. Cases related to commercial food were rare or absent, but in recent years (2017–2018), their percentage has increased to 32.56%. The HDI and botulism have an inverse mathematical correlation and predictable logical relationship: with an HDI increase, the incidence of FB decreased. In general, food botulism in Ukraine is related to traditional socioeconomic factors related to cultural food habits. In the face of declining living standards and uncertainty that food products will be physically or economically available, homemade preservation increases. Home food preservation is a major cause of botulism in Ukraine. The elimination of FB is possible in Ukraine only with the complete cessation of home canning and state control over the manufacture and sale of commercial canned products.

Toxemia in Human Naturally Acquired Botulism

Human botulism is a severe disease characterized by flaccid paralysis and inhibition of certain gland secretions, notably salivary secretions, caused by inhibition of neurotransmitter release. Naturally acquired botulism occurs in three main forms: food-borne botulism by ingestion of preformed botulinum neurotoxin (BoNT) in food, botulism by intestinal colonization (infant botulism and intestinal toxemia botulism in infants above one year and adults), and wound botulism. A rapid laboratory confirmation of botulism is required for the appropriate management of patients. Detection of BoNT in the patient's sera is the most direct way to address the diagnosis of botulism. Based on previous published reports, botulinum toxemia was identified in about 70% of food-borne and wound botulism cases, and only in about 28% of infant botulism cases, in which the diagnosis is mainly confirmed from stool sample investigation. The presence of BoNT in serum depends on the BoNT amount ingested with contaminated food or produced locally in the intestine or wound, and the timeframe between serum sampling and disease onset. BoNT levels in patient's sera are most frequently low, requiring a highly sensitive method of detection. Mouse bioassay is still the most used method of botulism identification from serum samples. However, in vitro methods based on BoNT endopeptidase activity with detection by mass spectrometry or immunoassay have been developed and depending on BoNT type, are more sensitive than the mouse bioassay. These new assays show high specificity for individual BoNT types and allow more accurate differentiation between positive toxin sera from botulism and autoimmune neuropathy patients.

Early recovery of botulism: one decade of experience

BACKGROUND

Botulism is a rare but serious disease, which appears in different forms. In this study, we reviewed the clinical features, laboratory data, and outcomes of patients who referred to our tertiary center.

MATERIALS AND METHODS

All confirmed cases of botulism referred to an academic referral center and a teaching hospital during 2009-2019, were retrospectively reviewed.

RESULTS

Fifty-three cases of clinical or laboratory-confirmed botulism were examined in this study. Nineteen patients were confirmed by laboratory data (serotype A (89.5%) and serotype E (10.5%)). In seven cases, the cause of botulism was unclear. In two patients, systemic symptoms emerged after the therapeutic injection of botulinum neurotoxin. The majority of cases (83%) were caused by an obvious food source. In 66% of cases, the initial symptoms emerged within less than 36 h, while in 20.8% of cases, the symptoms developed within or after 36 h; however, in seven patients that their botulism sources were unclear, the onset could not be estimated. All patients showed cranial involvement and generalized manifestation, and 49.1% had gastrointestinal symptoms. Except for two patients who were not treated due to immediate drug reactions who manifested severe hemodynamic instability, the rest of the patients were treated with trivalent antitoxin (A, B, and E). The complete resolution of the symptoms during hospitalization was documented in 50.9% of the patients. About 17% of the patients were intubated. Two patients died due to massive bilateral pulmonary thromboembolism and cardiac asystole following respiratory failure.

CONCLUSIONS

Although the complete resolution of the symptoms usually takes several weeks, in our experience, most patients showed at least partial resolution upon discharge. Early treatment results in better outcomes.

Foodborne Botulism: Clinical Diagnosis and Medical Treatment

Botulinum neurotoxins (BoNTs) produced by Clostridia species are the most potent identified natural toxins. Classically, the toxic neurological syndrome is characterized by an (afebrile) acute symmetric descending flaccid paralysis. The most know typical clinical syndrome of botulism refers to the foodborne form. All different forms are characterized by the same symptoms, caused by toxin-induced neuromuscular paralysis. The diagnosis of botulism is essentially clinical, as well as the decision to apply the specific antidotal treatment. The role of the laboratory is mandatory to confirm the clinical suspicion in relation to regulatory agencies, to identify the BoNTs involved and the source of intoxication. The laboratory diagnosis of foodborne botulism is based on the detection of BoNTs in clinical specimens/food samples and the isolation of BoNT from stools. Foodborne botulism intoxication is often underdiagnosed; the initial symptoms can be confused with more common clinical conditions (i.e., stroke, myasthenia gravis, Guillain–Barré syndrome—Miller–Fisher variant, Eaton–Lambert syndrome, tick paralysis and shellfish or tetrodotoxin poisoning). The treatment includes procedures for decontamination, antidote administration and, when required, support of respiratory function; few differences are related to the different way of exposure.

Interpol review of toxicology 2016-2019

This review paper covers the forensic-relevant literature in toxicology from 2016 to 2019 as a part of the 19th Interpol International Forensic Science Managers Symposium. The review papers are also available at the Interpol website at: https://www.interpol.int/content/download/14458/file/Interpol%20Review%20.Papers%202019.pdf.

Human Botulism in France, 1875-2016

Botulism is a rare but severe disease which is characterized by paralysis and inhibition of secretions. Only a few cases had been reported at the end of the 19th century in France. The disease was frequent during the second world war, and then the incidence decreased progressively. However, human botulism is still present in France with 10-25 cases every year. Food-borne botulism was the main form of botulism in France, whereas infant botulism (17 cases between 2004 and 2016) was rare, and wound and inhalational botulism were exceptional. Type B was the prevalent botulism type and was mainly due to consumption of home-made or small-scale preparations of cured ham and to a lesser extent other pork meat products. In the recent period (2000-2016), a wider diversity of botulism types from various food origin including industrial foods was reported. Severe cases of type A and F botulism as well as type E botulism were more frequent. Albeit rare, the severity of botulism justifies its continued surveillance and recommendations to food industry and consumers regarding food hygiene and preservation practices.

High prevalence of Clostridium botulinum in vegetarian sausages

Clostridium botulinum is a significant food safety concern due to its ability to produce highly potent neurotoxin and resistant endospores. Vegetarian sausages have become a popular source of plant protein and alternative for meat products. While vegetarian sausages have not been linked to botulism, numerous outbreaks due to preserved vegetables suggest a frequent occurrence of C. botulinum spores in the raw material. The product formulation of vegetarian sausages involves limited NaCl and preservatives, and shelf-lives may be several months. The safety of vegetarian sausages thus relies mainly on heat treatment and chilled storage. The main food safety concern is C. botulinum Group II that can grow and produce toxin at refrigeration temperatures. Here we show a high overall prevalence (32%) of C. botulinum in 74 samples of vegetarian sausages from seven producers. Both Groups I and II strains and genes for neurotoxin types A, B, E and F were detected in the products. The highest cell counts (1200 spores/kg) were observed for C. botulinum Group II in products with remaining shelf-lives of 6 months at the time of purchase. We conclude that vacuum-packaged vegetarian sausage products frequently contain C. botulinum spores and may possess a high risk of C. botulinum growth and toxin production. Chilled storage below 3°C and thorough reheating before consumption are warranted.

Adult Intestinal Toxemia Botulism

Intoxication with botulinum neurotoxin can occur through various routes. Foodborne botulism results after consumption of food in which botulinum neurotoxin-producing clostridia (i.e., Clostridium botulinum or strains of Clostridiumbutyricum type E or Clostridiumbaratii type F) have replicated and produced botulinum neurotoxin. Infection of a wound with C. botulinum and in situ production of botulinum neurotoxin leads to wound botulism. Colonization of the intestine by neurotoxigenic clostridia, with consequent production of botulinum toxin in the intestine, leads to intestinal toxemia botulism. When this occurs in an infant, it is referred to as infant botulism, whereas in adults or children over 1 year of age, it is intestinal colonization botulism. Predisposing factors for intestinal colonization in children or adults include previous bowel or gastric surgery, anatomical bowel abnormalities, Crohn's disease, inflammatory bowel disease, antimicrobial therapy, or foodborne botulism. Intestinal colonization botulism is confirmed by detection of botulinum toxin in serum and/or stool, or isolation of neurotoxigenic clostridia from the stool, without finding a toxic food. Shedding of neurotoxigenic clostridia in the stool may occur for a period of several weeks. Adult intestinal botulism occurs as isolated cases, and may go undiagnosed, contributing to the low reported incidence of this rare disease.

The First Case of Botulism in a Donkey

Botulism, a severe neuroparalytic disease that can affect humans, all warm-blooded animals, and some fishes, is caused by exotoxins produced by ubiquitous, obligate anaerobic, spore-forming bacteria belonging to the genus Clostridium and named botulinum neurotoxin (BoNT)-producing clostridia. This report presents the case of a 3-year-old donkey mare referred for progressive and worsening dysphagia of four days’ duration. Her voluntary effort in eating and drinking was conserved, and she was able to slow chew without swallowing. A complete neurological examination was performed, and botulism was strongly suspected. The ability to swallow feed and water returned on the tenth day of hospitalization and improved progressively. The jenny was discharged from the hospital after fifteen days. During the hospitalization, the Italian National Reference Centre for Botulism confirmed the diagnosis: mare’s feces were positive for BoNT/B and Clostridium botulinum type B.

Type E Botulinum Neurotoxin-Producing Clostridium butyricum Strains Are Aerotolerant during Vegetative Growth

Botulinum neurotoxins, the causative agents of the potentially fatal disease of botulism, are produced by certain Clostridium strains during vegetative growth, usually in anaerobic environments. Our findings indicate that, contrary to current understanding, the growth of neurotoxigenic C. butyricum strains and botulinum neurotoxin type E production can continue upon transfer from anaerobic to aerated conditions and that adaptation of strains to oxygenated environments requires global changes in proteomic and metabolic profiles. We hypothesize that aerotolerance might constitute an unappreciated factor conferring physiological advantages on some botulinum toxin-producing clostridial strains, allowing them to adapt to otherwise restrictive environments.

Clostridium butyricum, the type species of the genus Clostridium, is considered an obligate anaerobe, yet it has been shown to grow in the presence of oxygen. C. butyricum strains atypically producing the botulinum neurotoxin type E are the leading cause of type E human botulism in Italy. Here, we show that type E botulinum neurotoxin-producing C. butyricum strains growing exponentially were able to keep growing and producing toxin in vitro upon exposure to air, although less efficiently than under ideal oxygen-depleted conditions. Bacterial growth in air was maintained when the initial cell density was higher than 10³ cells/ml. No spores were detected in the cultures aerated for 5 h. To understand the biological mechanisms allowing the adaptation of vegetative cells of C. butyricum type E to oxygen, we compared the proteome and metabolome profiles of the clostridial cultures grown for 5 h under either aerated or anaerobic conditions. The results indicated that bacterial cells responded to oxygen stress by slowing growth and modulating the expression of proteins involved in carbohydrate uptake and metabolism, redox homeostasis, DNA damage response, and bacterial motility. Moreover, the ratio of acetate to butyrate was significantly higher under aeration. This study demonstrates for the first time that a botulinum neurotoxin-producing Clostridium can withstand oxygen during vegetative growth.

IMPORTANCE Botulinum neurotoxins, the causative agents of the potentially fatal disease of botulism, are produced by certain Clostridium strains during vegetative growth, usually in anaerobic environments. Our findings indicate that, contrary to current understanding, the growth of neurotoxigenic C. butyricum strains and botulinum neurotoxin type E production can continue upon transfer from anaerobic to aerated conditions and that adaptation of strains to oxygenated environments requires global changes in proteomic and metabolic profiles. We hypothesize that aerotolerance might constitute an unappreciated factor conferring physiological advantages on some botulinum toxin-producing clostridial strains, allowing them to adapt to otherwise restrictive environments.

Foodborne botulism in Turkey, 1983 to 2017

OBJECTIVE

The aim of this study is to assess the epidemiology of foodborne botulism cases which were seen and published in Turkey.

MATERIAL AND METHODS

This study covers the cases and outbreaks of botulism that have been identified and published in any region of Turkey, between 1983 and 2017. This systematic review was performed in accordance with the guidelines for performing and reporting systematic reviews and meta-analyses. The search was done on PubMed and Google in English and Turkish languages. Demographic features of the cases, nutritional sources, the development process of the disease, clinical symptoms and signs, the duration of hospitalization, treatment and mortality rates were analyzed.

RESULTS

Totally 95 patients (57 female and 38 male) were assessed from the published. The food which caused the majority of intoxication cases was canned green beans, and all the foods were home-canned goods. There cords showed that botulism antitoxin was given to 56 patients. The time from exposure to illness onset was 26.9 h. While 18 patients died at the end of follow-up and treatment (mortality 19%), 77 patients were discharged with full recovery.

CONCLUSION

Among 95 botulism cases, spread in Turkey over the last 35 years, the predominant source of toxin was home-canned food and green beans, in particular. Since community and emergency room physicians may be the first to treat patients with any type of botulinum intoxication, they must know how to diagnose and treat this rare but potentially lethal disease.