Type C/D botulism in the waterfowl in an urban park in Italy

This report describes an outbreak of botulism occurred among a free-living population of mallards (Anas platyrhynchos) and geese (Anser anser) in an urban park. Mortality rate among investigated population was 86,8% (118 dead out of 136). Twenty-seven carcasses were collected for macroscopic examination and screened for microbiological, virological, toxicological investigations. A sick mallard was captured and neurological symptoms were observed. No causative agent of viral avian diseases was found in the examined animals and screening for environmental neurotoxic substances proved negative as well. In contrast, microbiological cultures from specimens tested positive for botulinum toxin-producing clostridia. Blood serum and fecal extract of the sick mallard proved positive for botulinum neurotoxin in the standard mouse protection test using reference Clostridium botulinum type C antitoxin. Gene content of cultured strains showed a mosaic composition of bont/C and bont/D sequences, defining them as type C/D chimeric organisms.

Implementing the Bruker MALDI Biotyper in the Public Health Laboratory for C. botulinum Neurotoxin Detection

Currently, the gold standard method for active botulinum neurotoxin (BoNT) detection is the mouse bioassay (MBA). A Centers for Disease Control and Prevention-developed mass spectrometry (MS)-based assay that detects active BoNT was successfully validated and implemented in a public health laboratory in clinical matrices using the Bruker MALDI-TOF MS (Matrix-assisted laser desorption ionization–time of flight mass spectrometry) Biotyper. For the first time, a direct comparison with the MBA was performed to determine MS-based assay sensitivity using the Bruker MALDI Biotyper. Mice were injected with BoNT/A, /B, /E, and /F at concentrations surrounding the established MS assay limit of detection (LOD) and analyzed simultaneously. For BoNT/B, /E, and /F, MS assay sensitivity was equivalent or better than the MBA at 25, 0.3, and 8.8 mLD₅₀, respectively. BoNT/A was detected by the MBA between 1.8 and 18 mLD₅₀, somewhat more sensitive than the MS method of 18 mLD₅₀. Studies were performed to compare assay performance in clinical specimens. For all tested specimens, the MS method rapidly detected BoNT activity and serotype in agreement with, or in the absence of, results from the MBA. We demonstrate that the MS assay can generate reliable, rapid results while eliminating the need for animal testing.

Foodborne botulism associated with home-preserved turnip tops in Italy

In Italy, foodborne botulism is a rare disease mainly due to home-preserved food. In the case reported here, clinical diagnosis was performed on the basis of clinical signs and referred consumption of home-preserved turnip tops in oil. Definitive diagnosis was performed by detection of botulinum toxin in sera and neuro-toxigenic organisms in stools and leftover food. This case report highlights the need of a high medical awareness, prompt clinical diagnosis, and synergic collaboration among the health authorities for a correct management of botulism as well as disease containment.

Recommended mass spectrometry-based strategies to identify botulinum neurotoxin-containing samples

Botulinum neurotoxins (BoNTs) cause the disease called botulism, which can be lethal. BoNTs are proteins secreted by some species of clostridia and are known to cause paralysis by interfering with nerve impulse transmission. Although the human lethal dose of BoNT is not accurately known, it is estimated to be between 0.1 μg to 70 μg, so it is important to enable detection of small amounts of these toxins. Our laboratory previously reported on the development of Endopep-MS, a mass-spectrometric‑based endopeptidase method to detect, differentiate, and quantify BoNT immunoaffinity purified from complex matrices. In this work, we describe the application of Endopep-MS for the analysis of thirteen blinded samples supplied as part of the EQuATox proficiency test. This method successfully identified the presence or absence of BoNT in all thirteen samples and was able to successfully differentiate the serotype of BoNT present in the samples, which included matrices such as buffer, milk, meat extract, and serum. Furthermore, the method yielded quantitative results which had z-scores in the range of -3 to +3 for quantification of BoNT/A containing samples. These results indicate that Endopep-MS is an excellent technique for detection, differentiation, and quantification of BoNT in complex matrices.

Centrifugal microfluidic platform for ultrasensitive detection of botulinum toxin

We present an innovative centrifugal microfluidic immunoassay platform (SpinDx) to address the urgent biodefense and public health need for ultrasensitive point-of-care/incident detection of botulinum toxin. The simple, sample-to-answer centrifugal microfluidic immunoassay approach is based on binding of toxins to antibody-laden capture particles followed by sedimentation of the particles through a density-media in a microfluidic disk and quantification by laser-induced fluorescence. A blind, head-to-head comparison study of SpinDx versus the gold-standard mouse bioassay demonstrates 100-fold improvement in sensitivity (limit of detection = 0.09 pg/mL), while achieving total sample-to-answer time of <30 min with 2-μL required volume of the unprocessed sample. We further demonstrate quantification of botulinum toxin in both exogeneous (human blood and serum spiked with toxins) and endogeneous (serum from mice intoxicated via oral, intranasal, and intravenous routes) samples. SpinDx can analyze, without any sample preparation, multiple sample types including whole blood, serum, and food. It is readily expandable to additional analytes as the assay reagents (i.e., the capture beads and detection antibodies) are disconnected from the disk architecture and the reader, facilitating rapid development of new assays. SpinDx can also serve as a general-purpose immunoassay platform applicable to diagnosis of other conditions and diseases.

Simultaneous and sensitive detection of six serotypes of botulinum neurotoxin using enzyme-linked immunosorbent assay-based protein antibody microarrays

Botulinum neurotoxins (BoNTs), produced by Clostridium botulinum, are a group of seven (A-G) immunologically distinct proteins and cause the paralytic disease botulism. These toxins are the most poisonous substances known to humans and are potential bioweapon agents. Therefore, it is necessary to develop highly sensitive assays for the detection of BoNTs in both clinical and environmental samples. In the current study, we have developed an enzyme-linked immunosorbent assay (ELISA)-based protein antibody microarray for the sensitive and simultaneous detection of BoNT serotypes A, B, C, D, E, and F. With engineered high-affinity antibodies, the BoNT assays have sensitivities in buffer ranging from 1.3fM (0.2pg/ml) to 14.7fM (2.2pg/ml). Using clinical and food matrices (serum and milk), the microarray is capable of detecting BoNT serotypes A to F to similar levels as in standard buffer. Cross-reactivity between assays for individual serotype was also analyzed. These simultaneous, rapid, and sensitive assays have the potential to measure botulinum toxins in a high-throughput manner in complex clinical, food, and environmental samples.

Molecular immune recognition of botulinum neurotoxin B. The light chain regions that bind human blocking antibodies from toxin-treated cervical dystonia patients. Antigenic structure of the entire BoNT/B molecule

We recently mapped the regions on the heavy (H) chain of botulinum neurotoxin, type B (BoNT/B) recognized by blocking antibodies (Abs) from cervical dystonia (CD) patients who develop immunoresistance during toxin treatment. Since blocking could also be effected by Abs directed against regions on the light (L) chain, we have mapped here the L chain, using the same 30 CD antisera. We synthesized, purified and characterized 32 19-residue L chain peptides that overlapped successively by 5 residues (peptide L32 overlapped with peptide N1 of the H chain by 12 residues). In a given patient, Abs against the L chain seemed less intense than those against H chain. Most sera recognized a limited set of L chain peptides. The levels of Abs against a given region varied with the patient, consistent with immune responses to each epitope being under separate MHC control. The peptides most frequently recognized were: L13, by 30 of 30 antisera (100%); L22, by 23 of 30 (76.67%); L19, by 15 of 30 (50.00%); L26, by 11 of 30 (36.70%); and L14, by 12 of 30 (40.00%). The activity of L14 probably derives from its overlap with L13. The levels of Ab binding decreased in the following order: L13 (residues 169-187), L22 (295-313), L19 (253-271), and L26 (351-369). Peptides L12 (155-173), L18 (239-257), L15 (197-215), L1 (1-19) and L23 (309-327) exhibited very low Ab binding. The remaining peptides had little or no Ab-binding activity. The antigenic regions are analyzed in terms of their three-dimensional locations and the enzyme active site. With the previous localization of the antigenic regions on the BoNT/B H chain, the human Ab recognition of the entire BoNT/B molecule is presented and compared to the recognition of BoNT/A by human blocking Abs.

Outbreak of foodborne botulism linked to barbecue, Austria, 2006

On 3 July 2006, public health authorities in northern Austria were informed by a local hospital of a possible botulism outbreak affecting four people who had been admitted two days earlier.

Evaluation of lateral flow assays for the detection of botulinum neurotoxin type A and their application in laboratory diagnosis of botulism

Four lateral flow assays (LFAs) were evaluated for the detection of purified botulinum neurotoxin A, toxin complex, and unpurified culture supernatant. They included the BioThreat (Tetracore, Rockville, MD), SMART (New Horizons Diagnostics, Columbia, MD), BADD (ADVNT Biotechnologies, Phoenix, AZ), and RAMP (Response Biomedical, Burnaby, BC, Canada) assays. BioThreat and SMART did not detect the purified toxin. The best sensitivity was achieved with the RAMP test (50 ng mL(-1)). BioThreat and SMART measured as low as 10 ng mL(-1) of the toxin complex. Specificity data differed among the tests. BADD gave false-positive signals with uninoculated bacterial culture medium. BioThreat and RAMP were further evaluated with clinical sample matrices (serum, gastric, and rectum contents from pigs). Because of matrix effects and a generally low positive response, the assays are unsuitable for the direct detection of the toxin. However, the LFAs can be a helpful tool in screening bacterial cultures for toxigenic Clostridium botulinum, if further validated according to the laboratory needs.

Rapid detection of Clostridium botulinum toxins A, B, E, and F in clinical samples, selected food matrices, and buffer using paramagnetic bead-based electrochemiluminescence detection

Sensitive and specific electrochemiluminescence (ECL) assays were used to detect Clostridium botulinum neurotoxins serotypes A, B, E, and F in undiluted human serum, undiluted human urine, assay buffer, and selected food matrices (whole milk, apple juice, ground beef, pastry, and raw eggs). These novel assays used paramagnetic bead-based electrochemiluminescent technology in which biotinylated serotype-specific antibodies were bound to streptavidin-coated paramagnetic beads. The beads acted as the solid support and captured analyte from solution. Electrochemiluminescent detection relied on the use of ruthenium chelate-labeled anti-serotype antibodies and analysis with a BioVeris M-Series M1R analyzer. The sensitivities of the assays in clinically relevant matrices were 50 pg/ml for serotypes A and E, 100 pg/ml for serotype B, and 400 pg/ml for serotype F. The detection limits in selected food matrices ranged from 50 pg/ml for serotype A to 50 to 100 pg/ml for serotypes B, E, and F. The antibodies used for capture and detection exhibited no cross-reactivity when tested with the other serotypes. When purified native toxin was compared with toxins complexed to neurotoxin-associated proteins, no significant differences in assay response were noted for serotypes A, B, and F. Interestingly, the native form of serotype E exhibited reduced signal and limit of detection compared with the complexed form of the protein. We suspect that this difference may be due to trypsin activation of this particular serotype. The assays described in this article demonstrate limits of detection similar in range to the gold standard mouse bioassay, but with greatly reduced time to data. These rapid sensitive assays may have potential use in clinical settings, research studies, and screening of food products for botulinum toxins.

The use of Endopep-MS for the detection of botulinum toxins A, B, E, and F in serum and stool samples

Botulinum neurotoxin (BoNT) causes the disease botulism, which can be lethal if untreated. Previous work in our laboratory focused on developing Endopep-MS, a mass spectrometric-based endopeptidase method for the detection and differentiation of BoNT serotypes. We have expanded this effort to include an antibody capture method to partially purify and concentrate BoNT from serum and stool extract samples for the Endopep-MS assay. Because complex matrices such as serum and stool contain abundant endogenous proteases, this technique was needed to remove most proteases from the sample while concentrating BoNT from a sample size of 100 to 500 microl to 20 microl. When this antibody capture method is combined with the Endopep-MS reaction, limits of detection in 500mul of spiked human serum are 10 mouse LD50 (20 mouse LD50/ml) for BoNT A, 0.5 mouse LD50 (1 mouse LD50/ml) for BoNT B, 0.1 mouse LD50 (0.2 mouse LD50/ml) for BoNT E, and 0.5 mouse LD50 (1 mouse LD50/ml) for BoNT F. The limits of detection in spiked stool extracts are somewhat higher due to the high-protease environment of stool extract that also requires use of protease inhibitors. The entire method can be performed in as short a time as 4 h.

[Botulism in a neonate]

Botulism was suspected in a 17-day-old breastfed infant who developed over 2 days progressive muscular weakness and hypoventilation. The patient also presented with pupil dilation and light unresponsiveness. The electroencephalogram was normal. Full recovery was obtained after 85 days of artificial ventilation. Diagnosis was confirmed by the presence of the botulin toxin B in the patient serum. The source of the infection was not identified.

Toxicoinfectious Botulism in Commercial Caponized Chickens

During the summer of 2003, two flocks of commercial broiler chickens experienced unusually high death losses following caponizing at 3 wk of age and again between 8 and 14 wk of age. In September, fifteen 11-wk-old live capons were submitted to the Iowa State University Veterinary Diagnostic Laboratory for assistance. In both flocks, the second episode of elevated mortality was associated with incoordination, flaccid paralysis of leg, wing, and neck muscles, a recumbent body posture characterized by neck extension, and diarrhea. No macroscopic or microscopic lesions were detected in affected chickens. Hearts containing dotted blood and ceca were submitted to the National Wildlife Health Center in Madison, WI. Type C. botulinum toxin was identified in heart blood and ceca by mouse bioassay tests. Enzyme-linked immunosorbent assay tests on heart blood samples were also positive for type C. botulinum toxin. Clostridium botulinum was isolated from the ceca and genes encoding type C. botulinum toxin were detected in cecal contents by a polymerase chain reaction test. Chickens are less susceptible to botulism as they age, and this disease has not previously been documented in broilers as old as 14 wk of age. Wound contamination by spores of C. botulinum may have contributed to the unusually high death losses following caponizing.

[Three infants with constipation and muscular weakness: infantile botulism]

Two previously healthy infants, a boy of 10 weeks and a girl of 4 months presented with apathy and muscle weakness. A third previously healthy child, a girl of 6 weeks old was admitted with respiratory insufficiency. None of the three had had a bowel movement for a number of days. After extensive investigations which revealed few abnormalities Clostridium botulinum toxin was obtained in serum from all three children. Type-B-toxin was shown in the faeces of the older girl and boy; both recovered quickly. The other girl had type-A toxin; she died. Two of the three children were given honey to comfort them. Infantile botulism must be considered in every infant with symptoms of constipation and hypotonia. The diagnosis can quickly be confirmed by electromyography with repetitive 50-Hz-stimulation. Honey is a well-known source of the C. botulinum spore and should not be given to children under the age of 12 months. These three children are the first cases to be described in the Netherlands.

Botulism type E outbreak associated with eating a beached whale, Alaska

We report an outbreak of botulism that occurred in July 2002 in a group of 12 Alaskan Yu'pik Eskimos who ate blubber and skin from a beached beluga whale. Botulism death rates among Alaska Natives have declined in the last 20 years, yet incidence has increased.

Wound botulism in the UK and Ireland

There are three main, naturally occurring, epidemiological types of botulism: food-borne, intestinal colonization (infant botulism) and wound botulism. The neurological signs and symptoms are the same for all three epidemiological types and may include respiratory paralysis. Wound botulism is caused by growth of cells and release of toxin in vivo, is associated with traumatic wounds and abscesses and has been reported in drug users, such as those injecting heroin or sniffing cocaine. Up to the end of 1999 there were no confirmed cases of wound botulism in the UK. Between the beginning of 2000 and the end of December 2002, there were 33 clinically diagnosed cases of wound botulism in the UK and Ireland. All cases had injected heroin into muscle or by 'skin popping'. The clinical diagnosis was confirmed by laboratory tests in 20 of these cases. Eighteen cases were caused by type A toxin and two by type B toxin.

Microfluidic tectonics platform: A colorimetric, disposable botulinum toxin enzyme-linked immunosorbent assay system

A fabrication platform for realizing integrated microfluidic devices is discussed. The platform allows for creating specific microsystems for multistep assays in an ad hoc manner as the components that perform the assay steps can be created at any location inside the device via in situ fabrication. The platform was utilized to create a prototype microsystem for detecting botulinum neurotoxin directly from whole blood. Process steps such as sample preparation by filtration, mixing and incubation with reagents was carried out on the device. Various microfluidic components such as channel network, valves and porous filter were fabricated from prepolymer mixture consisting of monomer, cross-linker and a photoinitiator. For detection of the toxoid, biotinylated antibodies were immobilized on streptavidin-functionalized agarose gel beads. The gel beads were introduced into the device and were used as readouts. Enzymatic reaction between alkaline phosphatase (on secondary antibody) and substrate produced an insoluble, colored precipitate that coated the beads thus making the readout visible to the naked eye. Clinically relevant amounts of the toxin can be detected from whole blood using the portable enzyme-linked immunosorbent assay (ELISA) system. Multiple layers can be realized for effective space utilization and creating a three-dimensional (3-D) chaotic mixer. In addition, external materials such as membranes can be incorporated into the device as components. Individual components that were necessary to perform these steps were characterized, and their mutual compatibility is also discussed.

[Clinical and epidemiological analysis of patients with botulism hospitalized at the Department of Infectious Disease, Medical University of Lublin in 1990-2000]

In the paper we presented results of clinical and epidemiological analysis of 32 patients with botulism hospitalized at the Department of Infectious Diseases, Medical University of Lublin in 1990-2000. In the studied group, the relationships between botulism incidence and sex and place of residence were not significant. The incubation period ranged from 7 hours to 5 days (average 36 hrs). The clinical manifestations of botulism were typical in all cases. In one female patient the course of disease was complicated. She developed right-sided bronchopneumonia and left-sided purulent parotitis. The type B botulinum toxin occurred more frequently than the other types and the cases without serological confirmation (Chi 2 = 6.125 p = 0.01). It was found in serum of 23 patients (in 2 cases together with the type A toxin). The type E toxin was found in serum of one patient. The presence of toxin in serum was not detected in 8 patients. In all patients trivalent (types A, B and E) equine antitoxin was administered. The dose ranged from 50 to 150 cm3. Symptomatic treatment was given in all cases. Nobody required mechanical ventilation. The duration of hospitalization ranged from 5 to 28 days (average 16.6 days). A few patients complained of long-lasting blurred vision or dry mouth.

Rapid and sensitive detection of biological warfare agents using time-resolved fluorescence assays

We have achieved sensitive, rapid and reproducible detection of three biological threat agents in a variety of biological and environmental matrices using the DELFIA time-resolved fluorometry (TRF) assay system (Perkin-Elmer Life Sciences, Akron, OH). Existing ELISA assays for the detection of Francisella tularensis, Clostridium botulinum A/B neurotoxin (BotNT A/B), and Staphylococcus aureus enterotoxin B (SEB) were converted to TRF assays. They use 100 microl of positive control or unknown per test well and require just over 2 h to run. Fluorescent signal read time is a fraction of a second per well. The assay format consists of a capture ELISA utilizing a biotinylated capture antibody, prebound to a streptavidin-coated 96-well plate and a lanthanide (Europium, Eu3+)-labeled detector antibody. The bound Eu-labeled detector antibody produces a fluorescent signal upon the addition of an enhancement solution. The signal results from the dissociation of the Europium from the antibody, creating a micelle, thus amplifying the signal nearly one million-fold. Sensitivities achieved by these assays were between 4 and 20 pg/ml in buffer. Additionally, we have tested this system in different matrices such as serum, urine, dirt, and sewage. Concentration curves generated from standard solutions produced a wide linear range making serial dilutions of unknown samples unnecessary. DELFIA TRF assays are significantly better in terms of sensitivity, linear range, and run time than standard capture ELISAs and should facilitate early detection of potential biological warfare agents in clinical and environmental samples.

Visceral botulism--a new form of bovine Clostridium botulinum toxication

There are reports of a hitherto unknown bovine disease in Germany. The symptoms are, in general, indigestion (constipation alternating with diarrhoea), non-infectious chronic laminitis, engorged veins, oedemas, retracted abdomen, emaciation and apathy. Most cases occur during the peripartal period and often result in unexpected death. In addition, there are findings of delayed growth and wasting in heifers, as well as decreasing milk yield. Clinical and standard laboratory examinations leave the origin undisclosed. Bioassays for Clostridium botulinum, its spores and toxins in animals of affected farms revealed the presence of free botulinum toxin in the contents of the lower sections of the intestine. In two control farms without signs of the disease, the tests remained negative. This seems to support our hypothesis that long-lasting absorption of low quantities of botulinum toxin may interfere with the neurological control of intestinal physiology. The authors propose to name this disease complex 'visceral botulism'.

Extracorporeal adsorption as a new approach to treatment of botulism

Botulism is a paralytic disease caused by a toxin produced by the bacterium Clostridium botulinum. Outbreaks of the illness take place with a mortality rate of 10%, and the potential terrorist use of the toxin has become a serious concern. The current treatment includes administration of antitoxin, which can cause serious allergic reactions. Recently, we have successfully treated a 64 year old woman with the illness with IMMUSORBA TR350 (Asahi Medical, Tokyo, Japan), an extracorporeal adsorptive column containing polyvinylalcohol-tryptophan as an adsorptive agent, which has been widely used in Japan to treat myasthenia gravis and Guillain-Barre syndrome. Initially, the patient developed ocular muscle weakness and a variant of the Guillain-Barre syndrome was suspected. After extracorporeal treatment, her neurologic symptoms remarkably improved. After a series of treatments, botulinum toxin type B was isolated in the food she had eaten, establishing the diagnosis. An in vitro study revealed that the adsorptive column removed botulinum toxin to a significant extent. Our recent findings suggest that treatment with the adsorptive column TR350 can be a feasible option for botulism, which is a rare but potentially lethal disease.

Type C botulism in dairy cattle from feed contaminated with a dead cat

Four hundred twenty-seven of 441 adult Holstein dairy cattle from a 1,200-cow dairy died over a 1-week period during early spring 1998. Affected animals were from 4 late lactation pens, one of which included the bull string. Signs included weakness, recumbency, watery diarrhea, and death. Eighty animals from the 4 pens were dead approximately 8 hours after the first ill cows were noted. Affected cows would collapse on stimulation and extend all 4 limbs with moderate rigidity. Several lacked lingual tonus and had abdominal breathing patterns. The animals had been fed a load of total mixed ration that included a rotten bale of oat hay containing a dead cat. No common toxicants were identified, and pathologic examination revealed no consistent lesions. Testing of tissue from the cat carcass found in the feed sample using mouse protection bioassay identified the presence of type C botulinum toxin. Samples of feed, tissue from affected animals, cat tissue from feed, milk, and serum were also tested using an enzyme-linked immunosorbent assay (ELISA) specific for type C botulinum. Two samples of rumen contents were tested and found to be positive for botulism by ELISA, and 1 of 3 liver samples had a weak positive finding. No botulinum toxin was found in milk or sera using the ELISA.

Preliminary evaluation of a simple in vitro test for the diagnosis of type C botulism in wild birds

An enzyme-linked immunosorbent assay (ELISA) was developed for the detection of type C botulinum toxin (Clostridium botulinum) in wild birds. This simple, antigen-capture ELISA utilizes polystyrene immunosticks as the solid substrate, chicken antitoxin (IgY) as the coating antibody, rabbit antitoxin as the primary antibody, and peroxidase-labeled goat-anti-rabbit as the secondary antibody. To evaluate the immunostick ELISA as a diagnostic test for avian botulism, known concentrations of toxin were added to heparinized blood collected from healthy birds and tested by both the ELISA and mouse bioassay. Also, blood samples from 236 bird carcasses submitted to the National Wildlife Health Center (NWHC) for cause of death determinations were tested by both procedures. Using < or = 0.5 ml as the test volume for both procedures, the ELISA was less sensitive, detecting 0.25 ng/ml of toxin compared to 0.12 ng/ml for the mouse bioassay. Using the same volume of test sample for diagnostic submissions (< or = 0.5 ml), the ELISA was positive for 60% of the 149 clinically-diagnosed cases of botulism, whereas the mouse bioassay was positive for 79%. However, we demonstrated that with larger sample volumes (> or = 1.0 ml), the sensitivity of the ELISA may be equivalent or better than the mouse test due to the concentrating effect of the ELISA procedure. These preliminary results suggest that when adequate sample volumes are available, the immunostick ELISA can replace the mouse test for the diagnosis of botulism in wild birds.

Type E botulism associated with vacuum-packaged hot-smoked whitefish

On January 16, 1997 two Germans got botulism after eating hot-smoked Canadian whitefish produced in Finland. The serum sample of one of the patients contained 6 MLD/ml of botulinum toxin. The type of toxin was identified as E by the toxin neutralization test and the botulinum neurotoxin type E (BoNT/E) gene was also amplified from the serum by polymerase chain reaction (PCR), but C. botulinum could not be isolated from the positive serum sample. The remains of the hot-smoked whitefish eaten by the patients contained botulinum toxin detected by the mouse bioassay and the BoNT/E gene as determined by PCR. C. botulinum was isolated from the fish sample and it was confirmed to be type E by the mouse bioassay and by PCR. Eleven other fish samples from the same lot did not contain botulinum toxin nor any BoNT gene. The incriminated food was processed on the 9th and 10th of January, 1997 from frozen whitefish imported to Finland from Canada. The pulsed-field gel electrophoretic pattern of the isolated C. botulinum strain resembled a reference strain of North American origin. It did not match any C. botulinum strains isolated from the Baltic sea-bottom or from the fish caught in the area indicating that the fish was contaminated by C. botulinum in Canada. The conditions resulting in toxin production could not be identified. The safety problems associated with vacuum-packaged hot-smoked fish seem to be of utmost concern and the product is one of the most important botulism food vehicles processed on an industrial scale. Temperature monitoring and the use of time-temperature indicators are to be recommended in order to ensure adequate storage temperature from processing through to consumption. Allowing the use of nitrate and nitrite together with sufficiently high NaC1 concentration in this particular product should also be considered.

Infant botulism during a one year period in San Luis, Argentina

Five cases of infant botulism which occurred during the period from May 1995 to May 1996 in San Luis, Argentina, are reported. Infant botulism was confirmed in all patients by isolation of Clostridium botulinum type A from stool culture and by the toxin assay. Toxin was found in the serum of one of them. All patients required hospitalization with treatment consisting of supportive especially respiratory and nutritional care. At the time of discharge from the hospital, three patients had a good recovery, although two of them had mild difficulties in sucking or constipation. C. botulinum was not detected in samples of honey which had been given to two of the patients.

Botulism

Equine botulism is being recognized with increasing frequency by veterinarians throughout North America. Muscular weakness and dysphagia that progress during a period of 1 to 4 days, in the absence of laboratory derangements that indicate the presence of systemic disease, are suggestive of botulism. A tentative diagnosis usually is based on the presence of the following findings on physical examination: delayed pupillary light response, mydriasis, ptosis, generalized weakness, decreased tail tone, and slow prehension of feed. Definitive diagnosis requires detection of botulinum toxin in plasma, serum, gastrointestinal contents, or body tissues. Early treatment with antitoxin generally results in a favorable outcome. Botulism in foals and adult horses can be prevented by vaccination.

[Epidemic of type B botulism: Sion, December 1993-January 1994]

12 cases of food-borne botulism were registered in Sion, Switzerland, between 31 December, 1993 and 12 January, 1994. A type B toxin was isolated from the serum of one patient and from the incriminated ham. Clinical data of 10 male patients aged 21 to 54 years and some epidemiologic data are reported. The clinical course was mild to moderate with predominant autonomic and gastro-intestinal symptoms and signs: blurred vision (10 patients of 10), dry mouth with dysphagia (9/10), asthenia (7/10), diarrhea and/or constipation (7/10), nausea and vomiting (6/10), abdominal cramps (5/10), impaired sexual function (5/10), dilated pupils (4/10). Some discomfort (mainly blurred vision, asthenia and impaired sexual function) persisted for several months in most patients. Neuromuscular involvement was never the reason for seeking medical assistance and had often disappeared at the time of the first visit. Two patients were hospitalized, one for transient ileus of unknown origin and the second (first suspected case) for monitoring and infusion of trivalent equine botulinum antitoxin. This treatment was administered on day eight after intoxication and had no effect on this patient's outcome when compared with others. No patient died. Epidemiology, diagnosis, treatment and prognosis of botulism are discussed.

Use of sentinel mallards for epizootiologic studies of avian botulism

Captive-reared mallards (Anas platyrhynchos) were used as sentinels to study the epizootiology of avian botulism at the Sacramento National Wildlife Refuge, Willows, California (USA) from 1986 to 1989. Sentinel mallards were wing-clipped, and 40 to 50 birds were confined in 1.6-ha enclosures in 11 selected wetlands (pools). Enclosures were searched intensively three to four times weekly from July through October. Sick and dead wild and sentinel birds were collected, necropsied, and tested for type C botulism toxin. Botulism epizootics occurred in sentinel mallards in 1986, 1987, and 1989, but only a few isolated cases of botulism were detected in 1988. In most epizootics, botulism also was detected simultaneously in wild birds using the same pool outside the enclosure. Epizootics in sentinels were initiated and perpetuated in the absence of vertebrate carcasses. A sex-specific trend in the probability of intoxication was detected, with males contracting botulism at a higher rate than females. Daily mortality rates of sentinels during botulism epizootics ranged from 0.0006 to 0.0600, with a mean of 0.0190. These rates would result in the daily loss of 0.6 to 60 birds per thousand at risk. The use of sentinel birds provided an effective means of gathering site-specific epizootiologic data.

Retrospective study of 108 cases of botulism in Poitiers, France

Botulism, a food-borne toxin-mediated disease caused by Clostridium botulinum is still a common disease, which is most frequent in the rural environment; 108 cases, 66 males and 42 females, average age 32 years, were recorded from 1965 to 1990 in the infectious disease department of the University Hospital of Poitiers (France). In 83% of patients, the food responsible was home-cured ham. Mean incubation time was 3.4 days; digestive symptoms were observed in 93% of cases, ocular symptoms in 92% and urinary tract dysfunction in 22%. A scale of severity was used to classify the patients into those suffering from severe (6), intermediate (50) and mild (52) forms of the disease. Botulinum toxin type B was found in 36 (52%) of 69 blood samples and in 41 (51%) of 81 samples of the suspected food. From 1965 to 1976, 44 patients were treated with both toxoid and heterologous equine serotherapy. Since 1976, 29 patients have been treated with guanidine hydrochloride (35 mg/kg daily) and 35 patients with guanidine hydrochloride plus heterologous serotherapy. All 108 patients recovered without any sequelae.

Botulinum antibodies in dystonic patients treated with type A botulinum toxin: frequency and significance

We measured serum antibodies to botulinum toxin (ABT) in 96 patients with focal dystonia who had been treated with type A botulinum toxin. The frequency of detectable ABT was 3% (three patients). Patients with ABT had received more than 50 ng of botulinum toxin, and the shortest time between two injections was significantly less than in patients without ABT. The clinical evolution of the three patients was heterogeneous: one had decreased effectiveness with repeated injections, another had persistent improvement, and the third never responded to toxin injections.

Clinical and laboratory comparison of botulism from toxin types A, B, and E in the United States, 1975-1988

Cases of adult botulism (n = 309) were studied to identify clinical differences between toxin types and to evaluate the sensitivity of diagnostic laboratory testing. Patients with illness from type E toxin had the shortest incubation periods. Sporadic case-patients were more severely ill: 85% required intubation compared with only 42% in multiperson outbreaks. Of patients with type A botulism, 67% required intubation compared with 52% with type B and 39% with type E. Toxin testing was positive for 40%-44% of serum and stool specimens obtained within 3 days of toxin ingestion and for 15%-23% of specimens obtained thereafter, while 37% of stool specimens obtained > 3 days after toxin ingestion were positive by culture. Patients with type A botulism have more severe illness. In general, specimens obtained early are more likely to be positive by toxin assay, and stool cultures are more sensitive than toxin detection for specimens obtained later in the illness.

Clostridium botulinum type-C intoxication associated with consumption of processed alfalfa hay cubes in horses

An episode of nervous system dysfunction was observed in horses on 17 premises in 4 counties of southern California. Thirty-eight horses were affected, and 31 of those died. The common clinical signs of disease in the affected horses were: increased appetite; anxious attitude; rythmic, intermittent muscle tremors in the area of the tricep muscles; decreased palpebral tone; mydriasis; small hard fecal balls; and tendency to become sternally recumbent with the neck extended. The temporal distribution of cases on all 17 premises suggested a relationship between exposure to a common batch of alfalfa hay cubes and manifestations of similar clinical signs of disease in affected horses. Fifteen horses were submitted for necropsy. Diagnosis of botulism was established on the basis of detection of type-C1 toxin in the feed, in intestinal contents of 1 horse, and in the liver of the aforementioned horse and another horse. Toxigenic strains of Clostridium botulinum type-C were isolated from intestinal contents of 5 affected horses, one of which also contained type-C1 and type-C2 toxins. Seven of 10 horses treated with type-C antitoxin and plasma obtained from horses hyperimmunized with C botulinum type-C toxoids survived.

[Detection of Clostridium botulinum toxin in the blood of patients and in meat products]

Epidemiological data from the whole country reveal that insufficiently salted and dried hams are the main cause of the botulism in our country. In suspected hams as well as in a small number of patients' sera Cl Botulinum toxin type B was the most frequently found one up to the present time. Cl botulinum toxin was examined in our laboratory for several years and it was confirmed by the biologic test in 50% samples of the incriminated home made ham and in 35% patients' sera samples. Toxins type A and 1 were found in sera and in ham samples only toxin type B was found. It is suggested that consumers should be better informed concerning the risk of insufficiently processed delicatessen intake.

Observations on PCBs and mercury in common loons (Gavia immer) collected from southwestern Lake Michigan

The death of common loons (Gavia immer) was associated with a small spill of bunker-C oil off the Chicago shoreline of Lake Michigan. Petroleum oil was not found on the feathers or in the lungs of the birds. Botulinus toxins C and E were found in heart blood. Because the carcasses were autolysed, botulism toxins could have been produced postmortem. An average of 97 micrograms PCBs (Aroclor 1254 standard) and 2.2 micrograms dieldrin/g of body fat also were found. Concentrations of heavy metals in one bird were 0.25 microgram of total mercury and 0.5 microgram of lead/g of liver, respectively. The loons had abundant body fat suggesting they were not debilitated at the time of death.

[A patient with botulism caused by Clostridium botulinum type B]

A case of botulism type B acquired in The Netherlands is presented. The diagnosis was made on clinical grounds and positive mouse bio-assay. The patient was a man aged 37 years. Additional evidence was obtained by electromyography, single fibre electromyography and autonomic function tests. Antitoxin was administered without side effects. The clinical outcome was good.

[Food-borne botulism and its epidemiological features as seen in our country during the last few years]

We evaluated and presented here, the features of the eleven cases of food-borne botulism who admitted to the Infectious Diseases Department of Ibni Sina Hospital of Ankara University. Three of the cases admitted in 1984 and eight of them admitted in 1987. All of the cases were caused by home-prepared foods which had been eaten without cooking; the types of the food were green beans and pepper with sauce. In these cases the main symptoms and signs were generalized muscular weakness, dry mouth, dysphagia, diplopia, ptosis of the eyelids; besides these the other clinical symptoms and signs were seen in some patients. Although toxin couldn't be detected in the patients' sera by mouse-toxin neutralization, the EMG findings supported our diagnoses. To the three patients in the first group, botulinal anti-toxin was not given and two of them died. Anti-toxin was administered to the seven patients in the second group, none of them died.

Type C botulism in cattle being fed ensiled poultry litter

A botulinum toxin from ensiled poultry litter which caused a major outbreak of bovine botulism was characterised as type C1. The litter produced transient ataxia when fed to two experimental calves and the clinical signs were accompanied by a transient appearance of serum toxin. Type C1 toxin was demonstrated in muscle tissues which had been taken during the outbreak from an affected animal with high circulating serum toxin, and held frozen for seven months. Clostridium botulinum type C organisms were demonstrated in faeces from another affected animal and also in kidney tissue from a third animal. These observations have implications for the diagnosis and management of future outbreaks of botulism and for the potential health risk from the meat of affected animals.

An outbreak of type E botulism among common loons (Gavia immer) in Michigan's upper peninsula

An epizootic of type E botulism (Clostridium botulinum) occurred among common loons (Gavia immer) along the Lake Michigan shore of Michigan's Upper Peninsula (USA) during October and November 1983. An estimated 592 dead loons washed ashore along the Garden Peninsula. Type E botulinal toxin was demonstrated in blood samples and stomach contents of dead loons, and in samples of three species of dead fish found on the Lake Michigan shore. We suspect that loons acquired botulism by ingesting sick or dead fish containing type E toxin.

Laboratory findings in four cases of adult botulism suggest colonization of the intestinal tract

There was laboratory evidence of intestinal colonization in four cases of adult botulism confirmed by the Centers for Disease Control. No performed toxin was detected in available foods, but Clostridium botulinum was isolated from foods in two instances. Botulinal toxin was detected in the sera of all four patients, in one case at 47 days after ingestion of suspected food. C. botulinum was demonstrated in the stool of all four patients and persisted for 119 days after the onset of illness in one patient. Two patients had surgical alterations of the gastrointestinal tract, which may have promoted the colonization. The apparent lack of ingestion of performed toxin in these cases and the persistence of botulinal toxin or C. botulinum, or both, for long periods in three of the patients suggest that colonization of the intestinal tract occurred.

Botulism from chopped garlic: delayed recognition of a major outbreak

Diagnosis of botulism in two teenaged sisters in Montreal led to the identification of 36 previously unrecognized cases of type B botulism in persons who had eaten at a restaurant in Vancouver, British Columbia, during the preceding 6 weeks. A case-control study implicated a new vehicle for botulism, commercial chopped garlic in soybean oil (P less than 10(-4)). Relatively mild and slowly progressive illness, dispersion of patients over at least eight provinces and states in three countries, and a previously unsuspected vehicle had contributed to prolonged misdiagnoses, including myasthenia gravis (six patients), psychiatric disorders (four), stroke (three), and others. Ethnic background influenced severity of illness: 60% of Chinese patients but only 4% of others needed mechanical ventilation (P less than 10(-3]. Trypsinization of serum was needed to show toxemia in one patient. Electromyography results with high-frequency repetitive stimulation corroborated the diagnosis of botulism up to 2 months after onset. Although botulism is a life-threatening disease, misdiagnosis may be common and large outbreaks can escape recognition completely.