With the increasing consumption, in our country of home-prepared canned foods, cases of botulism have been reported in recent years. Botulism is usually associated with food-borne botulism, infant botulism or wound infection, with three clinical tables [1,2]. Most of the cases of botulism are food-borne and involve home canned or home processed foods [2, 4-6]. Sometimes the source of the disease cannot be determined. Vegetables, especially those of more neutral pH such as asparagus, green beans, peppers and mushrooms, are responsible for most of the cases. Some cases are caused by products derived from fish and marina mammals. Food-borne botulism usually occurs in small epidemics, whereas the other forms are sporadic [1,7].
Three females, aged 11, 14, 34, and one male patient, aged 40, came to the clinic complaining of dizziness, abdominal pain, nausea, vomiting, dry mouth and generalized weakness. The patients had consumed uncooked salted vegetables prepared at home with çakşir (Ferula orientalis L.), a plant which grows in our region. The symptoms occured 8-18 h after they had eaten this food. After the first symptoms, diplopia, pitosis and dysphagia occured. The later symptoms and findings are shown in Table 1. The cases were diagnosed as botulism based on these symptoms and findings and the patients were hospitalized. On the second day of hospitalization, the female patient, aged 11, died with sudden respiratory arrest before any diagnostic test had been made. Mouse toxin-neutralization tests, using serum from the other patients, gave a negative result. A certain amount of expertise is necessary for the mouse test; however this was our first experience and we considered that the negative results are related to our inexperience. It is reported, furthermore, that diagnosis can only be confirmed in 50-75% of the cases with this test [2,4] and as all the food suspected of contamination was consumed, it cannot be examined. The patients were therefore diagnosed on clinical findings.
During the second and third day of hospitalization, patients required a tracheotomy and mechanical ventilation for respiratory failure. One needed ventilatory support for 21 days but the other case required it 55 days. The male patient, aged 40, developed pneumiona in the right lung on the fifth day but with the antibiotic treatment this resolved over 5 days. However, he died of a massive arterio-tracheal haemorrhage fistula occuring on day 40.
On the second and third day of hospitalization, trivalent (anti-ABE) equinal botulism antitoxin were administered to the three patients.
Food must be boiled in a pressure cooker in order to kill the spores of Clostridium botulinum. When boiled in water without increased pressure the spores are not killed. The toxin is heat-labile and inactivated at high temperatures. An acid environment and high salt concentration prevents bacteria from growing [1,7]. It is impossible to know on every occasion whether food is or is not contaminated. Contaminated food may be normal in appearance and taste [2,4,7]. Our patients had stated that the food they ate had normal appearance and taste. The incubation period of food-borne botulism is generally 12-36 h but may be as short as 6 h or long as 8 days. When the incubation period is brief, the prognosis is worse . The two patients who died had brief incubation periods. Deaths from botulism results from respiratory failure, long-term mechanical ventilatory complications, pulmonary or systemic infection [2,8]. In our cases, the death in the early period was due to sudden respiratory deficiency and the one in the later period was due to a complication of prolonged mechanical ventilation. The patients having ventilatory failure generally need ventilatory support for 2-8 weeks. But this duration may sometimes extend by 7 months .
The diagnosis of botulism, suspected on the clinical presentation, can be confirmed by isolation of C. botulinum and identification or detection of toxin with mouse bioassay in the patient's serum, stool or suspected food. In recent years, toxin detection with polymerase chain reaction has been used for the rapid diagnosis of botulism [3,7,9]. The most useful laboratory technique to confirm diagnosis of botulism is the mouse toxin neutralization test . However, with this test, diagnosis can only be confirmed in 50-75% of the cases [2,4]. The mouse bioassay using the serum of three patients did not give a positive result. Dowel et al. reported that the test for the detection of toxin in serum gave positive results in only one third of cases .
The treatment of botulism consists of symptomatic and supportive care. The benefit of antitoxic treatment should be discussed [4,6,10,11]. A hypersensitive reaction may occur in 21% of patients with antitoxic treatment [1,4,10], and in one of our patients erythematous skin eruption occurred with antitoxin administration.
While botulism cases reported in our country depend on eating uncooked canned vegetables such as peppers and beans, in our cases it is noticeable that the food made by çakşir, a regional plant, is a salted vegetable. We wanted to emphasize once again that the growth of C. botulinum is not suppressed in less than 10% salt and this food can therefore be a source of the disease.
H. A. ALICI*
*Department of Infectious Diseases, †Department of Anesthesiology-Reanimation and ‡Department of Microbiology, Atatürk University, School of Medicine, Erzurum, Turkey
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