AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

Botulism is a paralytic disease caused by the neurotoxins of Clostridium botulinum and in rare cases, Clostridium butyricum and Clostridium baratii. These gram-positive spore-forming anaerobes can be found in soil samples and marine sediments throughout the world. With a lethal dose to humans of less than 1 mcg, botulinum toxins are the most poisonous substances known and pose a great threat as an agent of biological warfare. It is estimated that one gram of aerosolized botulism toxin has the potential to kill 1.5 million people. Botulinum toxin is classified by the Centers for Disease Control and Prevention (CDC) as one of the six highest-risk threat agents for bioterrorism because of the high lethality, ease of production and transport, and need for prolonged intensive care treatment.

Investigations of Clostridium neurotoxin as a biological weapon have been carried out by various nations. The Japanese in World War II carried out human experiments on prisoners in Manchuria. Also in World War II, the British secretly used a botulism-impregnated grenade in the assassination of a German Gestapo officer. The United States studied botulinum toxin as a military bioweapon until President Nixon signed the Biological and Toxin Weapons Convention in 1972, ending all US biotoxin weapons research. Iraq and the Soviet Union stockpiled neurotoxin, with Iraq admitting to weaponizing thousands of liters of toxin in warheads after the 1991 Gulf War. An attempt at terrorist use of Clostridium toxin in the early 1990s by the Japanese Aum Shinryko cult against American military targets was unsuccessful.

The term botulus is derived from the Latin word for "sausage." An outbreak of clostridial "sausage poisoning" in Europe in the late 1700s was responsible for many deaths. A German physician, Dr. Justinus Kerner, published the first case descriptions of botulism in 1822, with experiments conducted on himself and laboratory animals.

Classification

Six forms of botulism are now described, depending on the route of acquisition.

The first form, food-borne botulism, follows the ingestion of preformed toxin in foods that have not been canned or preserved properly.

Wound botulism, caused by systemic spread of toxin produced by organisms inhabiting wounds, is associated with trauma, surgery, subcutaneous heroin injection, and sinusitis from intranasal cocaine abuse.

Infant botulism results from intestinal colonization of organisms in infants younger than 1 year. In this age group, normal intestinal flora may not have developed to the degree that prevents colonization by these organisms in healthy adults.

A fourth form, adult intestinal colonization botulism, has been described. Similar in pathogenesis to infant botulism, this form occurs in older children and adults with abnormal bowel, such as colitis, intestinal bypass procedures or, or in association with other conditions that may create local or widespread disruption in the normal intestinal flora.

Injection-related botulism is a result of inadvertent misadventures with injection of therapeutic pharmaceutical botulinum toxin.

Finally, inhalational botulism has recently been described. To date, the only human cases have been the result of inadvertent inhalation of toxin by laboratory workers. However, aerosolization and inhalation of botulinum toxin is considered a likely method for poison delivery in a bioterrorist attack.

Differences in antigenicity among the toxins produced by different strains of botulism-causing organisms allow for separation of the organisms into 7 distinct types (A-G). Types A, B, and E are the toxins most often responsible for disease in humans, whereas types C and D only cause disease in other animals (eg, nonhuman mammals, birds, fish). In rare instances, a single strain of organism may produce 2 toxins.

As alluded to earlier, clostridia other than C botulinum have been associated with a handful of cases of botulism. These include reports of food-borne and infant botulism associated with type E toxin produced by C butyricum. Adult and infant intestinal colonization botulism, associated with type F toxin-producing C baratii, has been documented.

In addition, strains of C botulinum have been classified into 4 groups based on their phenotypic characteristics and DNA homology.

• Group I organisms are proteolytic and produce toxins A, B, or F.
• Group II is nonproteolytic and can make toxins B, E, or F.
• Group III organisms produce toxins C or D.
• Group IV organisms, now identified as Clostridium argentinense, produce toxin type G, which has not been shown to cause neuroparalytic illness but has been associated with sudden death in Switzerland.

For more information, see Medscape's Bioterrorism Resource Center.

Pathophysiology

Epidemiology

Food-borne botulism, the first form of the disease to be identified, is responsible for approximately 1000 reported annual cases worldwide. While European cases most commonly are associated with type B contamination of home-processed meats, Alaskan, Canadian, and Japanese outbreaks often involve type E toxin in preserved seafood. Chinese cases involve type A toxin in home-processed bean products. A recently described case in Thailand was associated with ingestion of home-preserved bamboo shoots.

Most cases in the continental US are associated with home-canned vegetable products such as asparagus, green beans, and peppers. Of the average 30-40 food-borne US cases per year, 60% are type A, 18% type B, and 22% type E. Alaska, California, Michigan, Washington, New Mexico, Illinois, Oregon, and Colorado have the highest incidences of food-borne botulism.

The toxin type most often responsible for food-borne illness corresponds well with the geographic distribution of the toxigenic species. Type A is most common west of the Mississippi, type B east of the Mississippi, and type E in Alaska. Toxin type A produces a more severe illness than type B, which in turn is more severe than type E.

By far, home-processed foods are responsible for most (94%) outbreaks of food-borne botulism in the continental US. In fact, of the 6% of outbreaks caused by mass-produced commercial foods, most cases were attributed to consumer mishandling of commercial products.

Infant botulism occurs in children younger than 1 year, with 95% of the cases occurring in patients younger than 6 months. Peak susceptibility is in the 2- to 4-month range. In the 16 years following its identification in 1976, 1134 cases of infant botulism have been recorded in the United States. With approximately 60 cases of infant botulism reported each year, it is now the most frequently occurring form of botulism. The disease is most common in the western part of the United States. One half of all annual cases are reported in California, where the frequency of the toxin responsible is distributed equally between types A and B.

While the toxin types of food-borne botulism seem to reflect the distribution of toxigenic strains in the environment, the frequency of type B toxin in infantile botulism is disproportionately high. Although the case-fatality ratio for infant botulism in the US is less than 2%, the disease is suspected to be responsible for up to 5% of sudden infant death syndrome cases in California.

Although the ingestion of honey has been identified as a strong risk factor for the disease, it is found in fewer than 20% of case histories (and only 5% of case histories in California in recent years).

Other risk factors that have been reported include infants with higher birth weights and mothers who were older and better educated than the general population. Another reported risk factor was a decreased frequency of bowel movements (<1/d) for at least 2 months. Breastfeeding was associated with older age at onset of illness in type B cases.

Through 1992, only 1-3 cases of wound botulism were reported in the US each year. Two thirds of these cases were type A and almost one third were type B. One half of all cases were reported from California. In recent years, the number of reported cases of wound botulism has risen dramatically, with 11 cases in California in 1994 and 19 cases confirmed by the State Department of Health Services during the first 11 months of 1995. All but 1 of 40 cases reported in California, at this writing, involved drug abusers, many with subcutaneous injection or skin-popping of heroin.

Cases of adult colonization botulism have been increasingly reported in the literature. In some of these cases, C botulinum organisms, but no preformed toxin, could be found in foods the patients had ingested. These cases were associated with a prolonged latent period of up to 47 days postingestion before onset of symptoms. In one study, 2 of 4 patients had surgical alterations of the gastrointestinal tract that may have promoted colonization.¹ Jejunoileal bypass, surgery of the small intestine, and Crohn disease are among other reported factors predisposing adult patients for intestinal colonization.

Only rare cases of injection-related botulism have been reported, despite the increasingly common use of botulinum neurotoxin in neurology, ophthalmology, and dermatology practices. The standard packaging mandated by the FDA contains doses that are well below the human toxic level.

Pathogenesis

C botulinum is distributed widely throughout the environment and can be found in soil, freshwater and saltwater sediments, household dust, and on the surfaces of many foods. The toxins produced are cytoplasmic proteins (mass = 150 kDa) released as cells lyse. While the spores survive 2 hours at 100°C (but die rapidly at 120°C), the exotoxin is heat labile. It becomes inactivated after 1 minute at 85°C or 5 minutes at 80°C.

Although the mode of entry of toxin may differ between the different forms of diseases, once the toxin enters the bloodstream, it acts in a similar manner to produce the clinical symptoms. The toxin binds to receptors on presynaptic terminals of cholinergic synapses, is internalized into vesicles, and then is translocated to the cytosol. In the cytosol, the toxin mediates the proteolysis of components of the calcium-induced exocytosis apparatus (the SNARE proteins) to interfere with acetylcholine release. Blockade of neurotransmitter release at the terminal is permanent, and recovery only occurs when the axon sprouts a new terminal to replace the toxin-damaged one.

The effects of the toxin are limited to blockade of peripheral cholinergic nerve terminals, including those at neuromuscular junctions, postganglionic parasympathetic nerve endings, and peripheral ganglia. This blockade produces a characteristic bilateral descending paralysis of the muscles innervated by cranial, spinal, and cholinergic autonomic nerves but no impairment of adrenergic or sensory nerves, and no central nervous impairment. The classic syndrome of botulism is a symmetrical, descending motor paralysis in an alert patient, with no sensory deficits.

Mortality/Morbidity

• For food-borne botulism, patients with an early onset of clinical symptoms (within 36 h of toxin ingestion), index patients in food-borne cases, and patients older than 60 years generally have a longer clinical course than their counterparts.
• Deaths occurring within the first 2 weeks of botulism are most often due to failure to recognize the severity of disease or from pulmonary or systemic infection. The average duration of respiratory support for those requiring mechanical ventilation is 6-8 weeks but may be as long as 7 months.
• For food-borne botulism, severity of disease seems to be associated with toxin type. Intubation is required for 67% of patients with type A botulism, 52% of patients with type B, and 39% of patients with type E. In addition to being more likely to need ventilatory support, patients with type A botulism tend to see a physician earlier and have a longer course of illness than those with type B botulism. The case-fatality rate for type A botulism is 10%, twice that of type B.
• Ventilatory and upper airway muscle strength, along with exercise performance, predominantly build within the first 12 weeks, and most patients are back to normal within 1 year with type A botulism. Dyspnea, fatigue, and decreased maximal workload are common 2 years after type B intoxication, although lung function tests have returned to normal.
• The overall case-fatality rate is approximately 7-10%. For patients older than 60 years old, the fatality rate is approximately doubled. The mortality rate is lower for patients who receive prompt antitoxin compared with those with delayed treatment.
• Infant botulism progresses for 1-2 weeks and stabilizes for 2-3 weeks before recovery begins. The average length of a hospital stay for infants is approximately 1 month, although excretion of toxin and organisms may continue for more than 3 months following discharge. The infant case-fatality rate (1.3%) is low compared to food-borne illness, but a 5% relapse rate is associated with infant botulism after apparent resolution of clinical symptoms.
• The case-fatality rate of wound botulism is 10%, and survivors experience significant morbidity requiring prolonged medical care.²
• The occurrence of an episode of botulism does not necessarily confer immunity toward subsequent episodes. Immunization in the form of a pentavalent toxoid is available, but it is used only for those in high-risk areas such as laboratory workers and certain military personnel. It requires yearly boosters to remain protective.

CLINICAL

Section 3 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

History

• Although laboratory confirmation is necessary for a definitive diagnosis, clinical presentation, patient history, and physical examination (particularly neurologic exam) can be used as strong indicators for the presence of botulism. Due to the delay in laboratory confirmation and the necessity of treatment prior to the binding of the toxin to neurons, antitoxin should be empirically begun in patients with highly suggestive presentations.
• Place special attention on eliciting a complete patient history, including the following:
• • History of foods eaten, and any ill contacts who ate the same foods.
  • History of intravenous drug abuse (especially "skin popping")
  • Recent surgery or trauma
  • Gastrointestinal problems or intestinal bypass surgery

Physical

• Food-borne botulism
• • The CDC suggests attention to the following cardinal features:
    • Patient is afebrile unless another infection is present.
    • Patient demonstrates symmetric neurologic symptomatology.
    • Patient remains responsive, with intact sensation (14% of patients report some paresthesias or decreased sensation)
    • Patient has a normal or slow heart rate in the absence of hypotension.
    • Signs typically are not accompanied by sensory deficits, with the exception of blurred vision.
  • The neurologic symptomatology often has been described as a progressive, symmetric, descending weakness or paralysis that first affects muscles innervated by the cranial nerves, then progresses to involve muscles of the neck, arms, and legs. This occurs in an alert patient with intact sensorium and intact sensation.
  • The typical progression of symptoms (in order of appearance) in a botulinum neurotoxin poisoning can be summarized by the Dozen D's: dry mouth, diplopia, dilated pupils, droopy eyes, droopy face, diminished gag reflex, dysphagia, dysarthria, dysphonia, difficulty lifting head, descending paralysis, and diaphragmatic paralysis.
  • Respiratory difficulty arises from airway obstruction and diaphragmatic weakness. Diplopia, dysarthria, dry mouth, and generalized weakness are among the most common presenting symptoms. Other symptoms that have been associated with botulism include ptosis, dysphagia, sore throat, dysphonia, nystagmus, ataxia, paresthesias, paralytic ileus, severe constipation, urinary retention, and orthostatic hypotension.
  • Pupils are dilated or unreactive (ophthalmoplegia) in 50% of patients. Unless secondary complications such as respiratory failure develop, patients are alert and mental function is unimpaired.
  • Sensory deficits only have been reported in isolated cases. Neurologic symptoms may appear from 6 hours to 10 days after ingestion of toxin, with a median incubation period of 1 day.
  • Nausea, vomiting, and diarrhea often precede or accompany neurologic manifestations; constipation typically follows after neurologic signs have appeared. GI symptoms are more prominent in food-borne botulism and much less pronounced in cases of wound botulism.
• Infant botulism
• • The degree of involvement in this form of the disease can vary from asymptomatic to paralysis to sudden death.
  • A prominent and common sign of the disease is constipation (defined as 3 or more days without defecation). Other clinical features include listlessness, lethargy, difficulty in sucking and swallowing, hypotonia, weak cry, poor feeding, pooled oral secretions, generalized muscle weakness, and poor head control, which gives the infant a characteristic floppy appearance.
  • Neurologic findings include ptosis, ophthalmoplegia, sluggish pupillary reaction to light, flaccid expression, dysphagia, weak gag reflex, and poor anal sphincter tone.
  • Respiratory failure occurs in approximately 50% of diagnosed patients.
  • The incubation period (between the time of spore ingestion and onset of symptoms) associated with infant botulism varies from 3-30 days.
• Wound botulism
• • Patients often present with much of the same symptomatology that is observed in the food-borne form, including acute blurred vision, dysphagia, dysarthria, generalized weakness (with or without absence of deep tendon reflexes), and pupillary abnormalities. Gastrointestinal manifestations are absent.
  • The Clostridium-infected wound generally appears benign, without typical signs of infection (unless also infected by other bacteria, in which case a fever also may be present). In some cases, the wound is not apparent.
  • The average incubation period is 10 days.

DIFFERENTIALS

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Other Problems to be Considered

Congenital or autoimmune neuropathy or myopathy
Mushroom (muscarine) poisoning
Poliomyelitis
Tick paralysis

WORKUP

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Lab Studies

• Laboratory confirmation
• • Before treatment with antitoxin, obtain 10-15 mL of serum, 25-50 g of feces, and possibly 25-50 mL of fluid from gastric aspiration. Collect and refrigerate similar quantities of suspected food samples for testing. In constipated patients, a gentle saline enema may be required to obtain fecal specimens.
  • Label each specimen container with the patient's name, specimen type, date of collection, and medications being received, and send it to a state health department-approved reference laboratory in insulated cold packs. Contact your local health department for specific instructions.
  • Confirmation of the organism and/or toxin and toxin typing is obtained in almost 75% of cases. Early cases are more likely to be diagnosed by toxin assay, whereas later ones are more likely to have a positive culture. Laboratory confirmation of toxin presence is via a mouse bioassay, and identification of the toxin type is performed by a mouse toxin neutralization test.
• Food-borne botulism
• • For food-borne botulism, toxin is found in serum samples 39% of the time and in stools 24% of the time.
  • Organisms are found in cultures of stool samples 55% of the time.
  • Stool cultures generally are more sensitive than toxin detection for specimens obtained later (>3 d postingestion) in the course of illness.
• Infant botulism
• • In patients whom infant botulism is suspected, stools and enema fluids (with minimal water added to limit dilution of toxin) are the specimens of choice, as serum is only rarely toxin positive.
  • One also may wish to culture possible sources of clostridia, such as honey or house dust.
• Wound botulism: Wound botulism may be identified by detection of toxin in serum or by culture of wound specimens.
• Adult colonization botulism: Organisms may be detected in stool and toxin in serum for up to 119 days following the onset of symptoms.
• New methods of detection: In vitro methods of detection, including polymerase chain reaction-based detection of clostridial genes and ELISA identification of toxin, but these methods are not widely available outside of research institutions.

TREATMENT

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Emergency Department Care

Antitoxin should be administered as soon as the clinical diagnosis is established, as laboratory confirmation requires days. The early administration of antitoxin will not reverse the course of the intoxication but will prevent further progression of paralysis. This is the best method to prevent diaphragmatic involvement and the need for mechanical ventilation. Antitoxin can only bind neurotoxin free in the blood. Once in the neuron, it cannot be bound.

• Food-borne botulism
• • Monitor asymptomatic individuals who have eaten food suspected of being contaminated for the appearance of neurologic signs and symptoms.
  • Enemas and cathartics or whole-bowel irrigation may be used (if no ileus is present) to purge the gut of toxin. If ingestion occurred within the past few hours, emetics or gastric lavage may aid in the removal of toxin.
• Infant botulism: Most cases progress to complete respiratory failure. Intubation is required for a median of 16-23 days. Tracheostomy usually is not required.
• Wound botulism
  • Wound botulism requires thorough debridement of the wound site, even if it appears to be healing well.
  • Follow this by injection of 3% hydrogen peroxide to produce aerobic conditions. Hydrogen peroxide itself is not innocuous to tissues, and some have advocated using hyperbaric oxygen therapy if available.
  • Antitoxin may be injected directly into the wound site.
• • Urinary retention may require use of a catheter.
• Respiratory concerns
• • In adults, botulism results in pulmonary complications in 81% of patients, with ventilatory failure in one third.
  • Monitor spirometry, pulse oximetry, and arterial blood gas measurements, with particular attention placed on serial measurements of maximal static inspiratory pressure and respiratory vital capacity to help in predicting respiratory failure.
  • Strongly consider intubation and mechanical ventilation when vital capacity is less than 30% of predicted (or <12 mL/kg), particularly when absolute or relative hypercarbia and rapidly progressive paralysis with hypoxemia are evident.

Consultations

• Medical care providers who suspect botulism in a patient should immediately call their state health department's emergency 24-hour telephone number. The state health department will contact the CDC to report suspected botulism cases, arrange for a clinical consultation by telephone and, if indicated, request release of botulinum antitoxin. State health departments should call the CDC 24-hour telephone number at 770-488-7100. The call will be taken by the CDC Emergency Operations Center, which will page the Foodborne and Diarrheal Diseases Branch medical officer on call.
• Pulmonology for respiratory sequelae
• Surgery for wound care
• Infectious disease specialist for management issues

MEDICATION

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The goals of pharmacotherapy are to reduce morbidity and prevent complications. Medication commonly used in the treatment of botulism is described below. In addition to that described, guanethidine and 4-aminopyridine have been used for the treatment of botulinum paralysis but have not been shown to be effective.

The use of local antibiotics such as penicillin G or metronidazole may be helpful in eradicating C botulinum in wound botulism. Antibiotic use is not recommended for infant botulism because cell death and lysis may result in the release of more toxin. Aminoglycoside antibiotics and tetracyclines, in particular, may increase the degree of neuromuscular blockade by impairing neuronal calcium entry.

Drug Category: Antitoxin therapy

Therapy consists of approximately 10,000 IU of antibodies against toxin types A, B, and E to neutralize serum toxin concentrations.

Drug Category: Immune Globulin

FOLLOW-UP

Section 8 of 11  

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• Medication
• Follow-up
• Miscellaneous
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• References

Further Inpatient Care

• Ventilatory support
• Surgical debridement of wounds
• Pediatric nutritional support: Intravenous feeding (hyperalimentation) is discouraged because of its potential for secondary infection and because of the success with nasogastric or nasojejunal tube feeding.

Deterrence/Prevention

• Inform the public about the hazards of improperly preserved or canned foods.
• Inform expectant mothers not to administer honey to infants.

Complications

• Wound infection
• Respiratory distress

Prognosis

• Prognosis is generally good with early detection, early antitoxin administration, and intensive supportive therapy.

MISCELLANEOUS

Section 9 of 11  

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• Follow-up
• Miscellaneous
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Medical/Legal Pitfalls

• Delay in administration of antitoxin in a symptomatic patient.

MULTIMEDIA

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Media file 1:  Bioterrorist Agents. Signs and symptoms. Chart courtesy of North Carolina Statewide Program for Infection Control and Epidemiology (SPICE), copyright University of North Carolina at Chapel Hill, www.unc.edu/depts/spice/bioterrorism.html.
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Media file 2:  Courtesy of Arnon SS, et al. Botulinum toxin as a biological weapon: medical and public health management. JAMA 2001 Apr 25;285:1059.
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Media type:  Graph

REFERENCES

Section 11 of 11

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• References

1. McCroskey LM, Hatheway CL. Laboratory findings in four cases of adult botulism suggest colonization of the intestinal tract. J Clin Microbiol. May 1988;26(5):1052-4. [Medline].
2. Mechem CC, Walter FG. Wound botulism. Vet Hum Toxicol. Jun 1994;36(3):233-7. [Medline].
3. Arnon SS, Schechter R, Inglesby TV. Botulinum toxin as a biological weapon: medical and public health management. JAMA. Feb 28 2001;285(8):1059-70. [Medline].
4. Bigalke H, Rummel A. Medical aspects of toxin weapons. Toxicology. Oct 30 2005;214(3):210-20. [Medline].
5. Centers for Disease Control and Prevention. Botulism associated with commercially canned chili sauce--Texas and Indiana, July 2007. MMWR. Aug 3, 2007;56(30):767-9. [Medline].
6. Dunbar EM. Botulism. J Infect. Jan 1990;20(1):1-3. [Medline].
7. Fox CK, Keet CA, Strober JB. Recent advances in infant botulism. Pediatr Neurol. Mar 2005;32(3):149-54. [Medline].
8. Freedman M, Armstrong RM, Killian JM. Botulism in a patient with jejunoileal bypass. Ann Neurol. Nov 1986;20(5):641-3. [Medline].
9. Goonetilleke A, Harris JB. Clostridial neurotoxins. J Neurol Neurosurg Psychiatry. Sep 2004;75 Suppl 3:iii35-9. [Medline].
10. Hatheway CL. Botulism: the present status of the disease. Curr Top Microbiol Immunol. 1995;195:55-75. [Medline].
11. Horowitz BZ. Botulinum toxin. Crit Care Clin. Oct 2005;21(4):825-39, viii. [Medline].
12. Mandell GL, Bennett JE, Dolin R. Clostridium botulinum. In: Principles and Practice of Infectious Diseases. 4^th ed. 1995:2178.
13. Marks JD. Medical aspects of biologic toxins. Anesthesiol Clin North America. Sep 2004;22(3):509-32, vii. [Medline].
14. Mcnally RE, Morrison MB, Berndt JE, et al. Effectiveness of medical defense interventions against predicted battlefield levels of botulinum toxin A. Joppa, MD: Science Applications International Corp; 1994.
15. Park JB, Simpson LL. Progress toward development of an inhalation vaccine against botulinum toxin. Expert Rev Vaccines. 2004;3(4):477-87. [Medline].
16. Schmidt RD, Schmidt TW. Infant botulism: a case series and review of the literature. J Emerg Med. Nov-Dec 1992;10(6):713-8. [Medline].
17. Shukla HD, Sharma SK. Clostridium botulinum: a bug with beauty and weapon. Crit Rev Microbiol. 2005;31(1):11-8. [Medline].
18. Smith, LA; Rusnak, JM. Botulinum neurotoxin vaccines: past, present, and future. Crit Rev Immunol. 2007;27(4):303-18. [Medline].
19. Ting PT, Freiman A. The story of Clostridium botulinum: from food poisoning to Botox. Clin Med. May-Jun 2004;4(3):258-61. [Medline].
20. Underwood K; Rubin S; Deakers T; Neuth C. Infant botulism: a 30-year experience spanning the introduction of botulism immune globulin intravenous in the intensive care unit at Childrens Hospital Los Angeles. Pediatrics. Dec 2007;120(6):e1380-5. [Medline].
21. Weber JT, Hoeprich PD, et al. Botulism. In: Jordan MC, et al, eds. Infectious Diseases. 5^th ed. 1994:1185.
22. Wenham TN. Botulism: a rare complication of injecting drug use. Emerg Med J. Jan 2008;25(1):55-6. [Medline].
23. World Health Organization. Outbreak news. Botulism, Thailand. Wkly Epidemiol Rec. Mar 31 2006;81(13):118. [Medline].

Article Last Updated: Apr 10, 2008