Symptoms and Diagnosis of Botulism

Botulism is a toxicoinfectious disease caused by human infection with vegetative forms of botulinum clostridia with accumulated toxins. Microbiological studies have revealed seven varieties. For a person, types A, B, E and F. are most dangerous.

Symptoms of botulism are formed from the defeat of internal organs( brain and spinal cord, gastrointestinal tract) and severe intoxication. Differences in the course of children and adults are due to the unequal state of the intestinal microflora, the advantage of lactobacilli in an infant.

How does the infection occur?

The infection mechanism distinguishes 4 variants of the infection:

• food - a causative agent of botulism with toxins accumulates in food, enters the body of people during meals, the most dangerous are canned meat, fish, mushrooms, vegetables, dry and smoked fish, lard;
• wound - accompanies contaminated earth with open wounds, with soil from the botulinum clostridium entering the bloodstream, delayed wound treatment creates favorable conditions for growth and formation of toxins;
• children - except for a favorable microflora for the growth of bacteria, the role of infecting baby food through the components of honey plays a role;
• , unspecified - confirms the name by the absence of data on the route of infection.

What are the manifestations of botulism?

Botulism in humans is characterized by selective damage to motor neurons that transmit signals from the medulla oblongata through the spinal canal in the anterior horn to the muscle groups. Therefore, the origin of some clinical symptoms can be explained by the defeat of specific neuromuscular formations.

The first signs of botulism are:

• difficulty in swallowing, dry mouth, changing the tone of the voice, nasal speech, limited mobility of the tongue - this is due to the defeat of the cranial nerves in the medulla oblongata, which have anatomical pairs V, IX, XII;
• violation of joint and arbitrary eye movement( convergence), strabismus, omission of the eyelid, double vision in the eyes - is caused by the defeat of the central nuclei of cranial nerves III and IV;
• dilated pupils, reduced vision due to impaired accommodation( the ability to strain the muscles to change the curvature of the lens and adapt to different distances to objects) - is caused by a cessation of the functioning of the ciliary nerves and muscles;
• pallor - occurs due to spastic capillary contraction;
• reduction facial expressions - due to bilateral lesion of the facial nerves.

Diarrhea, vomiting - with botulism indicate the onset of exposure to botulinum toxin, pathogenic microorganisms in the eaten product of

In severe conditions, the main symptoms are:

• muscle weakness, paresis and paralyzes - first blocking the transmission of the nerve impulse, then triggering the mechanism of increasing oxygen starvation and metabolic disorders, the process of energy synthesis in cells;
• increased heart rate, increased blood pressure - caused by an increase in activity of sympathic-adrenal system, lack of oxygen( increases the production of catecholamine hormones);
• atonic constipation, bloating - a sign of oppression of the vagus nerve, an increase in the concentration of catecholamines;
• urinary retention - associated with a decrease in bladder tone, a lesion of the vegetative nervous system;
• frequent surface breathing - caused by paresis of the intercostal muscles, diaphragm, lack of support of the abdominal muscles, oxygen deficiency in the blood.

Symptoms of

The average incubation period lasts 18-24 hours from the time of infection. Variations are possible from several hours to 5 days. It is established that the shorter it is, the more difficult it is to expect the course of the disease. A critical period is considered 10 days, therefore, so much monitoring is conducted for contact persons.

All signs of botulism are usually divided into syndromes:

• gastrointestinal;
• is paralytic;
• is general toxic.

The first symptoms are often the patient's complaints about an unclear lesion of the stomach and intestines. There is nausea with vomiting, diarrhea, cramping pains in the epigastrium and around the navel. Signs reminiscent of poisoning, with botulism indicate the release of toxins into the blood.

The attentive doctor observes a discrepancy between infrequent diarrhea, hence, a moderate loss of fluid with pronounced dry skin and mucous membranes. And also the appearance of the patient's complaints on the "lump in the throat" and the difficulty of swallowing. This difference does not "fit" into the clinic of ordinary food poisoning.

Neurologic symptoms are detected simultaneously with gastrointestinal syndrome or on the second day. The earliest signs are dry mouth, visual impairment, weakness in the muscles. Patients feel before their eyes the "grid", "fog", "flickering flies" are not able to read due to broken accommodation and double-vision.

The face without mimicry resembles a mask, one or both eyelids are lowered, asymmetry of wrinkles and folds is possible, the pupils are dilated, they do not respond to light, or a very weak

reaction is observed. The examination reveals lethargy, different pupil widths in the left and right eye( anisocoria).Nystagmus is determined( twitching of eyeballs), strabismus. It is difficult for a patient to stick his tongue out, the action takes time and takes place in jerky movements. There is a general malaise, a headache. The temperature is slightly raised or normal.

Weakness in the muscles begins with the occipital region, so the patients hang their head and they try to support it with their hands. The gait is unstable. The intercostal muscles cause a shallow breathing in the paresis, imperceptible movements of the chest, the patient is not able to take a deep breath.

An important feature of the clinical manifestation is the preservation of sensitivity against the background of decreased motor muscle activity. It is used in differential diagnostics with paresis and paralysis caused by impaired cerebral circulation.

The paresis of the throat muscles first causes difficulty in swallowing solid food, then liquid. Examination of the mouth and nasopharynx shows a bright red coloration, dryness of the mucous membrane, a congestion of thick mucus in the epiglottis zone. Attachment of the infection causes turbidity and purulent raids. Therefore, the picture is mistaken for a sore throat.

Violated speech is one of the typical signs of botulism in adults. The changes follow in stages:

• first disturbs the timbre, the voice becomes husky due to lack of moisture in the vocal cords;
• then joins the paresis of the tongue, which is manifested by complete dysarthria, nasal congestion due to the sagging muscles of the palatine curtain;
• when the process reaches the muscles of the vocal cords, the nasal disappears.

It is important that the disturbed innervation of the larynx causes the absence of a protective cough push to get into the lumen of crumbs, mucus. Therefore, patients may suddenly suffocate. Disorders of the cardiovascular system are expressed in the expansion of the left border, tachycardia, arrhythmia, muffled tones.

When auscultation the doctor determines the accent of the 2nd tone on the pulmonary artery

How does the recovery period go?

The recovery period is slow. Improvement of the patient feels after the appearance of saliva in the mouth. Then comes back muscle strength. The longest is to treat vision, sometimes for several months. Still, there is a complete restoration. There are no residual manifestations.

How are the severity of the disease different?

The most appropriate course of treatment is to start with detecting the symptoms of poisoning in the patient, even if there is no certainty about the botulinum nature of the disease. The use of such measures as gastric lavage and bowel cleansing, enterosorbent intake, fluid administration allows to reduce the toxin concentration in the gastrointestinal tract, to withdraw it from the body.

By severity, the course of botulism is conventionally divided:

• on the lung - implies the development of paralysis only in the oculomotor muscles, signs of intoxication are weak, the voice changes moderately due to decreased saliva formation, the disease lasts up to 2-3 days;
• moderate - the paresis of the muscles of the larynx and pharynx is added to the eye damage, but before complete swallowing and aphonia disturbance does not reach, there are no serious disorders, the duration of the swelling period is 2-3 weeks;
• severe - a pronounced clinic with all manifestations, paresis and paralysis, complications, a feeling of suffocation, suppressed cough reflex, and the patients do not lose consciousness.

The state of these muscles depends on the usefulness of the act of breathing

Complications of

Complications of botulism are more often associated with the ingestion of vomit into the trachea and bronchi. Developing: aspiration pneumonia, purulent tracheobronchitis, atelectasis in the lung tissue( occlusion leading bronchioles and the collapse of a part of the lungs).

The fall of immunity is accompanied by the development of purulent parotitis( inflammation of the parotid salivary glands), an inflammatory reaction to the medical measures carried out - catheterization of the bladder, aspiration of saliva, artificial ventilation of the lungs, tracheostomy.

The most typical complication is the development of serum sickness( observed in 1/3 of patients who received antibotulinum serum).Myositis of the calf muscles occurs 2-3 weeks after the onset of the disease. The patient complains of pain in the calves during movements.

The most serious complication is acute respiratory failure. It is called "ventilation", because it is caused by the inability of respiratory movements against the background of lesions of the intercostal muscles and diaphragm.

Face and body become cyanotic. In contrast to lung damage, there is no pronounced dyspnea, excitation of the patient. From this violation, most patients with botulism die.

Another deadly complication is paralytic cardiac arrest

Manifestations of botulism in childhood

Children have three forms of botulism: food( most frequent), wound and infant disease. The clinical course is somewhat different from adults.

With food botulism

The incubation period lasts several hours or up to 12 days. It is determined by the dosage of the child's botulinum toxin. First, there are signs of vague poisoning and increasing intoxication:

• abdominal pains are localized in the epigastric region;
• is vomiting, older children complain of nausea;
• diarrhea is repeated up to 5 times a day, it is important that there are no impurities in the feces( mucus, pus, blood, fatty inclusions).

By the end of the day, the signs of intoxication( strong headache, dry mouth, thirst, weakness) come to the forefront, possibly a temperature increase of 39 degrees. After 24 hours, diarrhea ends and constipation and bloating occur. Neurological symptoms appear.

Visual impairment is expressed in the loss of the ability to see deleted objects, the contours blur, the "grid" in front of the eyes. When you try to read letters do not differ, there is a double vision. Pupils dilated, without reaction to light. There is strabismus, ovulation of the eyelids, the movement of the eyeballs is limited, the symptom is nystagmus.

Swallowing disorder( dysphagia) and speech( dysarthria) are caused by damage to the muscles of the larynx, the sky, the tongue. At first, the child complains of sore throats when swallowing, a "ball" that prevents swallowing food. Noticeably choking on food. In severe swallowing it is completely impossible, attempts to swallow the water end by flowing it through the nose. The tongue does not protrude. The voice becomes hoarse and nasal.

Because of ingestion of mucus and food in the respiratory tract, frequent suffocation and coughing occurs

It is possible to develop asymmetry of the face due to paresis of the facial nerve. The walk of the child is shaky, the coordination of movements is disturbed, weakness in the muscles of the arms and legs is determined. The heart sounds are sharply muffled, the systolic noise is listened, the left border is widened.

Neurological symptoms in children are manifested in various combinations, some classical symptoms may be absent. Lethal outcome is characterized by suddenness, occurs with any severity of the disease.

With other forms of botulism

Wound botulism is accompanied in children by a longer incubation period. It is characterized by the absence of gastrointestinal signs. Only neurological symptoms appear. In infants, a feature is considered to be more favorable conditions in the intestine for the germination of vegetative forms and the formation of a toxin.

Clinic develops slowly as synthesis and its passage into the blood. The form is typical for the age of 2 to 6 months. Infected with children who are on artificial feeding are infected more often. The source can be dust from the ground with spores, beekeeping products. It is not possible to set the incubation period.

The current has a tendency to both light forms and unexpected weighting. The initial symptoms of botulism include:

• lethargy of the baby;
• refusal to eat;
• the weakening of crying and crying;
• lack of a smile on his face.

Further development of all neurological manifestations is observed: eyelid drooping, choking, hoarse crying, lacrimation, dilated pupils, lack of stool. Acute respiratory failure is the main complication of botulism and the cause of death of babies.

Diagnostic methods

Unfortunately, in order to diagnose correctly, the doctor will not help specific clinical methods of diagnosis if botulism is suspected. In the general analysis of blood, urine and feces there are no characteristic changes.

Serological tests( detection of typical antibodies and antigens) are not performed in conventional laboratories, since the disease is not accompanied by the production of characteristic antibodies. The dosage of the toxin is too low to be determined, but is sufficient for clinical manifestations.

Studies at the bacteriological level are possible only in specialized laboratories where it is possible to work in an oxygen-free chamber. From the fecal and vomitic weights obtained from washing the stomach and intestines, the contents of wounds, food products used by the diseased, toxins are released.

The analysis is carried out on experimental mice, guinea pigs. They inject intraperitoneally a solution obtained by mixing the patient's blood with anti-botulinum serum( type A, B, E) followed by centrifugation. The whole study takes 4 days.

The specific type of toxin can be refined by setting the response of indirect hemagglutination, enzyme-labeled antibodies, precipitation in the gel. The causative agent of botulism is isolated by the method of sowing the contents of the stomach and intestine into special nutrient media for anaerobes.

Caseinovo-mushroom medium of Hosinger

is used for crops. The existing hardware electromyographic study allows detecting specific disorders at the level of synaptic signaling in botulism.

What should be considered reliable criteria for diagnosis?

In the diagnosis of botulism, epidemiological analysis of data on possible routes of infection, food research, a set of clinical symptoms helps. The following factors are considered:

• information on the patient's use of canned food suspected of being infected with clostridium botulism;
• no temperature when the severity of the condition increases;
• severe dry mouth;
• gradual strengthening of muscle weakness;
• characteristic diarrhea on the first day followed by constipation and bloating;
• eye symptoms;
• violation of the timbre of voice, swallowing;
• signs of ventilation respiratory failure. What diseases should be distinguished from botulism?

  Differential diagnosis of botulism requires a lot of practical experience of doctors of different specialties. After all, the disease is rare. Mistake can be diagnosed:

  • food poisoning( toxicoinfection) especially fungi;
  • disorders of cerebral circulation;
  • encephalitis;
  • effects of hypertensive crisis;
  • myasthenia gravis.

  Food toxic infections are caused by staphylococci, salmonella, E. coli. They are more often associated with eating dairy and confectionery, unprocessed eggs, violation of shelf life, production technology and maintenance conditions of

  . They have a short incubation period, the gastritis clinic prevails, the severity of the flow is caused by a large loss of water with diarrhea with enteritis. There is no respiratory failure. For signs of gastroenteritis typical fever, abdominal pain, the allocation of impurities with diarrhea, fetid smell of stool.

  In feces, bacteriological analysis reveals the type of pathogen.

  With encephalitis, headache, general malaise, and fever come first. Perhaps a partial disorder of the oculomotor nerves. Other neurologic manifestations of botulism are absent. Polyencephalitis is accompanied first by drowsiness, then by a transition to soporus and to whom.

  Observed eye signs in the form of paralysis gaze upward, speech impairment, a cerebellar form of changes in movements, trembling of the hands. Important distinctive features are determined when analyzing CSF from the spinal canal. With botulism, there is no change.

  Violation of cerebral circulation( stroke) occurs suddenly or with the gradual development of symptoms. Usually, the patient has predisposing factors( high blood pressure, transferred stress, vascular lesions with atherosclerosis, obesity and other endocrine diseases).The neurologist will clearly determine the foci of the disease due to impaired sensitivity, pathological reflexes that are not present in botulism.

  
  Belene, some unaware of the danger, grow in the garden

  Overdose of some drugs, domestic poisoning, negligent care of the child can contribute to the ingestion of atropine and similar drugs on the basis of belladonna, dope, and bleached( nightshade plants).Children can eat berries in the forest, in the country.

  The clinic is similar to botulism: the patient has a sharp dizziness, dry mouth, vomiting, speech and swallowing are difficult, pupils are dilated, vision is impaired. Distinguish the disease helps to clarify the origin of the symptoms, the typical psychomotor excitation of the patient, the presence of delirium, visual hallucinations, epileptiform seizures, marked signs of cardiovascular damage( tachycardia, arrhythmia, falling blood pressure).

  In adults who abuse alcohol, it is possible to poison with methanol. With him, too, there is a progressive visual impairment, pupil dilatation, a weak reaction to light, dry mouth, vomiting, cyanotic skin, rapid breathing at normal temperature.

  No characteristic of botulism changes in voice and choking, swallowing disorders. The patient in a serious condition falls into a coma, there is no acute insufficiency of breathing. It is easy to find out the relationship with the use of a surrogate of alcohol.

  Myasthenic bulbar paralysis occurs in patients with severe myasthenia flow. The patient has expressed bulbar and oculomotor changes( dysphagia, loss of voice and speech, omission of the eyelid, broken breathing, double vision).

  But there is no food or wound type of infection. Exacerbations are caused by advanced SARS, another disease. There are paralyzes of the extremities, weakened tendon reflexes. Difficulties in diagnosing botulism require urgent medical treatment of the patient for the smallest manifestations.