Ross J. Brechner, MD, MS, MPH
State Epidemiologist

• Diagnosis and treatment are based on clinical findings.
• Botulism should be suspected in any adult with a history of acute onset of bilateral cranial nerve (ptosis, dyplopia, dysarthria, dysphagia) dysfunction
• Bilateral cranial nerve findings are always present, and may be followed by progressive symmetric descending muscle weakness with or without ventilatory compromise
• Symptom progression may be rapid (hours) or slow (days)

  While the differential diagnosis in individual cases includes various rare conditions, in the setting of an outbreak the above findings are essentially pathognomonic.

  Normal CSF protein levels help distinguish botulism from Guillian-Barre syndrome and brain imaging (CT, MRI) helps rule out stroke syndrome. In a an outbreak or bioterrorism event involving many patients, these tests may be superfluous. When available, expertly performed electromyography (EMG) can provide a rapid, definitive diagnosis.

• Careful monitoring of respiratory vital capacity and mechanical ventilation when required
• Meticulous intensive care unit level care
• Request antitoxin from the CDC by calling the State Health Department

Administration of botulinum antitoxin

• Antitoxin should be administered as soon as possible after symptom onset
• Antitoxin will not reverse paralysis, but may arrest the progression of paralysis
• Antitoxin should NOT be given unless symptoms of botulism are present
• Most antitoxin of equine origin, and therefore can cause hypersensitivity reactions, including anaphylaxis and serum sickness. Prospective sensitivity testing should be performed on all recipients in accordance with package instructions.
• Antitoxin administration should not be repeated because circulating antitoxins have a half-life of 5 to 8 days

• be obtained prior to the administration of antitoxin:
• Serum: 15cc or 2 red top tubes for antitoxin testing, spin immediately
• Stool: 25-50 grams for toxin testing and culture. Use minimal enema fluid if required
• Gastric aspirate: 50mL for toxin testing and culture
• Wound: sterile sample of tissue or wound fluid in anaerobic container
• Food: any suspected food item, refrigerated in sealed original containe

• There is no prophylactic treatment for botulism.
• Persons who were exposed to botulinum toxin should be evaluated by a physician and carefully observed for the development of symptoms of botulism. If symptoms appear, the patient should be treated immediately with botulinum antitoxin.

• No licensed vaccine is available at this time, and vaccination is not considered an effective public health measure in the face of an acute outbreak or bioterrorism event

• Standard precautions should be exercised when evaluating and treating patients.
• Botulinum toxin cannot be absorbed through intact skin.
• Toxin can be absorbed through mucosal surfaces, the eye, or non-intact skin.
• No case of person-to-person transmission of botulinum has ever been described, including in patient-care settings.
• · Persons exposed to bodily fluids or stool of botulinum patients should be advised of the early signs of botulism, and report for evaluation if these are noted.

• As person-to-person transmission has not been documented, isolation is not required. Neither hospital staff nor other patients are at risk.
• Given the high positive predictive value of objectively noted symmetric cranial nerve palsies in previously healthy patients in the setting of a mass outbreak, all such patients should be diagnosed with probable botulism and be treated with antitoxin.
• Exposed persons should be observed closely, and if they develop symptoms compatible with botulism, they should be treated with antitoxin immediately.

• As person-to-person transmission has not been documented, isolation is not required. Neither hospital staff nor other patients are at risk.
• Given the high positive predictive value of objectively noted symmetric cranial nerve palsies in previously healthy patients in the setting of a mass outbreak,
• all such patients should be diagnosed with probable botulism and be treated with antitoxin.
• Exposed persons should be observed closely, and if they develop symptoms compatible with botulism, they should be treated with antitoxin immediately.
  

• Objects contaminated with secretions or body fluids should be disposed of as biohazardous waste.

• Staff should observe standard precautions when treating patients. Botulism is not transmitted person-to-person. Workers exposed to patient body fluids face a negligible risk. They should be made aware of the early symptoms of botulism and in the remote chance that these develop, they should be admitted and treated.
• In the event of exposure, assess the route of exposure, amount and serologic type of toxin involved, and the immune status of the exposed worker.
• Exposure to material from a clinical specimen carries negligible risk. If symptoms develop, the person should be hospitalized immediately and the case handled as possible botulism.