The Facts

Most people know that botulism is dangerous, but many are confused about whether it's an infection or a case of poisoning. In fact, it can be both. Clostridium botulinum is a worldwide bacterium that inhabits rivers, soil, and the guts of mammals, fish, and shellfish. It's not an organism that normally makes its living by attacking humans. We most often encounter C. botulinum by accident.

C. botulinum secretes a neurotoxin (nerve poison) that can weaken or paralyze muscles and can even cause death. This is botulin toxin, one of the most dangerous substances known. Botulism is the condition of having been poisoned with C. botulinum toxin.

Causes

Botulism is rare, but there are still cases every year.

There are three ways to get botulism:

• Foodborne botulism occurs when food contaminated with the toxin is eaten. The bacteria are dead or gone by the time you eat the food, but the toxin remains. Most foodborne botulism is attributed to home-canned foods, but outbreaks occasionally occur in commercially-prepared foods.
• Infant botulism occurs when infants under 12 months of age eat bacterial spores rather than the toxins. Spores of C. botulinum then grow in the infant's intestines where they produce toxins. Honey can contain spores of C. botulinum and is associated with infant botulism and should not be given to children under one year old. Infant botulism is rare.
• Wound botulism occurs when live bacteria infect an open cut and the toxin is carried through the body by the blood.

Occasionally, toxins can be inhaled or absorbed through the eyes.

Ironically, some people intentionally get botulism from their doctor these days. The toxin is used to make a medication that is injected into twitching and spasmodic muscles to calm them. It's a treatment used for a variety of nerve disorders and for the cosmetic purpose of removing frown lines, forehead wrinkles, and "crow's feet" around the eyes.

Botulism can cause death due to the lungs not functioning properly (respiratory failure). However, advancements in supportive care have greatly reduced the death rate, and now less than 10% of people who get botulism die from the condition.

Symptoms and Complications

C. botulinum toxin attacks nerve endings, permanently damaging them. It can't cross the barrier that protects the brain. The heart has its own wiring system and also isn't affected. However, botulin can affect all the other nerves of the body, including the nerves of the muscles that operate the lungs. Botulin toxin kills by shutting down breathing.

Symptoms usually appear quickly in foodborne botulism, within 18 to 36 hours, but a few people feel no symptoms for as many as 8 days after eating the poison. Vomiting, nausea, diarrhea, and abdominal cramps are the first signals. Then the neurological symptoms begin to appear - the muscles slowly shut down, starting with the temple and forehead and proceeding slowly down both sides of the body. The face goes slack and expressionless, the eyelids droop, and the victim may drool. Vertigo and double vision are common. The arms slowly get weaker, then the legs. Diarrhea is replaced by constipation. By this time there's also difficulty in talking, swallowing, and breathing. Temperature and pulse remain normal.

The first sign of infant botulism is constipation. The neurological symptoms are the same as in foodborne botulism but develop less rapidly. This is because the spores produce toxin slowly and the child absorbs it bit by bit instead of all at once as in foodborne botulism. The baby may also suck milk weakly, have difficulty crying loudly, lose head control, and lack facial expression.

Making the Diagnosis

Your doctor will ask you questions about your symptoms and perform a physical exam.

There is a test for botulin toxin, but it's only available in certain clinics. It involves injecting the suspected botulin toxin into a mouse that's received a toxoid, a sort of vaccine against poison.

Treatment and Prevention

Supportive care is provided to anyone with botulism. This may include hospitalization, use of a ventilator to help with breathing, and nursing care. Recovery can take many weeks as paralysis slowly improves.

An antitoxin is available that neutralizes botulin. However, the antitoxin needs to be administered as soon as possible after diagnosis. The medication can't repair nerve endings already damaged. This means that while you may survive, you will be left in the state you were in at the time the medication was administered. That may mean paralysis, sometimes to the point of being unable to talk or even swallow.

The good news is that you'll recover because new nerves can grow to replace those that were killed. However, this tends to be a slow recovery process and it may take a few weeks or months, even up to a year, for this to occur.

The antitoxin is generally not given for infant botulism.

For wound botulism, antibiotics are given in addition to supportive care.

Preventing botulism is usually possible. However, if you prepare and store a lot of your own food, you may be creating unnecessary risk. The C. botulinum bacterium is anaerobic, meaning it likes airless environments. This is why you can get foodborne botulism out of a can. Very few cases of botulism arise from commercially canned food. Most occur when individuals can their own products.

Botulin toxin has been found in North America in these foods:

• canned corn
• baked potatoes
• peppers
• green beans
• soups
• beets
• asparagus
• mushrooms
• ripe olives
• spinach
• tuna fish
• chicken, chicken livers, and liver paté
• luncheon meats
• ham
• sausage
• stuffed eggplant
• lobster
• smoked and salted fish
• garlic-in-oil dressing

Only highly acidic foods are safe from C. botulinum. Freezing will shut down toxin production, but a fridge isn't cold enough. The following food handling procedures can help you to prevent foodborne botulism:

• Preserved food should be heated to a temperature above 100°C (212°F) for at least 10 minutes during the canning process.
• Cook food at 79.9°C (176°F) for at least 30 minutes. This usually destroys toxins.
• Do not eat or store cooked foods that have been at room temperature for 4 hours or more.
• Do not eat foil-wrapped baked potatoes that have been left at room temperature, and do not store chopped garlic or onions in oil at room temperature.
• If eating home-canned food, boil it first with frequent stirring for 10 minutes.
• Do not feed honey to infants less than one year old.