1/3. Acute paralysis following "a bad potato": a case of botulism.PURPOSE: Intensivists often encounter patients with respiratory failure as a result of neuromuscular disease, however, acute neuro-muscular syndromes are less common. We present a case of food borne Clostridium botulism and discuss the diagnostic and therapeutic considerations. CLINICAL FINDINGS: A 35-yr-old healthy male presented with abdominal pain and blurred vision 12 hr after ingesting a "bad" potato. During the next 17 hr, the patient demonstrated a gradual descending paralysis which ultimately resulted in no cranial nerve function and 0/5 strength in all extremities. sensation was intact. The patient required intubation and mechanical ventilation. His blood count, biochemical profile, computerized tomography and magnetic resonance imaging of the head were normal. A lumbar puncture revealed no abnormalities. Due to the rapid deterioration and presentation of 'descending' paralysis, botulism was suspected. The patient was treated empirically with botulinum anti-toxin. Samples of blood, stool and gastric contents were cultured for the presence of clostridium botulinum and its toxin and these tests were positive for botulinum toxin A 12 days later. The patient's neuromuscular function gradually improved over a prolonged period of time. Six and one-half months after his initial presentation, the patient was discharged home after completing an aggressive rehabilitation program. CONCLUSIONS: botulism is a rare syndrome and presents as an acute, afebrile, descending paralysis beginning with the cranial nerves. If suspected, botulinum anti-toxin should be considered, particularly within the first 24 hr of onset of symptoms. Confirmation of the presence of botulinum requires days therefore the diagnosis and management rely on history and physical examination.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
2/3. Progression of clinical signs in severe infant botulism. Therapeutic implications.The clinical evaluation of nine patients with severe infant botulism revealed an identifiable progression of signs due to blockade of the cholinergic synapse similar to that described for competitive blocking agents. This predictable sequence reflects different "margins of safety" for muscles involved in repetitive activities, diaphragmatic function and movement of the extremities. It is important for the clinician to realize that return of peripheral motor activity does not signify a completely recovered cholinergic synapse. Instead of having a four- to five-fold margin of safety, the infant remains close to the point of neuromuscular blockade. Added insults or stress to neuromuscular transmission may precipitate respiratory failure. An understanding of the signs associated with progressive impairment of cholinergic synapses both during onset and during resolution of disease will allow safe care of the infant and will diminish the risk of iatrogenic complications. Evaluation of head control is the most sensitive physical finding indicative of return of adequate neuromuscular function and signifies that oral feedings can be reinstituted.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
3/3. Wound botulism.Wound botulism is a rare infectious and toxicologic complication of trauma and i.v. drug abuse. Only 39 cases have been reported in detail in the English literature. This case report describes a patient with wound botulism who presented to four medical facilities before receiving definitive diagnosis and treatment. Although his history and physical examination were consistent with wound botulism, diagnosis and therapy were delayed because this rare disease was not considered initially in the differential diagnosis. Wound botulism should be considered in trauma patients and i.v. drug abusers who present with cranial nerve palsies and descending paresis.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |