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Ophthalmologic Manifestations of Botulism

  • Author: Bhupendra Patel, MD, FRCS; Chief Editor: Hampton Roy, Sr, MD  more...
Updated: May 19, 2016

Practice Essentials

Botulism, although rare, is a potentially lethal illness caused by the botulinum toxin produced by Clostridium botulinum and other clostridial species.

Botulism causes cranial nerve palsies and flaccid paralysis of involuntary muscles and may result in respiratory compromise.

Early diagnosis is essential. Intensive supportive care and administration of botulinum antitoxin are vital.

Administration of human-derived botulinum antitoxin in suspected infant botulism cases decreases the length of hospitalization, intensive care unit admission, and mechanical ventilation.

Botulism must be reported to state public health departments and the Centers for Disease Control and Prevention at 770-488-7100.

Prevention involves keeping wounds clean and safe food preparation and food-canning techniques.

Honey should not be fed to children younger than 12 months based on multiple studies that have identified the association of honey consumption with infant botulism cases. This is supported by all major pediatric organizations.



Botulism is a disease caused by the neurotoxins of Clostridium botulinum. This microorganism is a spore-forming, gram-positive, anaerobic bacillus, which may exist in soil or marine sediments throughout the world. The neurotoxin causes a paralytic disease with blockade of neuromuscular conduction. Botulism is characterized by symmetric cranial nerve palsy, often followed by flaccid paralysis of involuntary muscles, which can result in respiratory compromise and death.

Botulism generally is seen in 4 clinical scenarios, as follows: (1) the ingestion of preformed toxins in food contaminated with C botulinum, (2) contamination of wounds by C botulinum, (3) colonization of the intestine by C botulinum in infants younger than 1 year, and (4) iatrogenic botulism due to injection of botulinum toxin.

Despite the uncommon nature of the disease, patients with botulism may present to an ophthalmologist with visual symptoms.

Purified botulinum toxin type A, in the form of BOTOX® purified neurotoxin complex, has been used therapeutically in the treatment of certain forms of strabismus and in blepharospasm associated with facial dystonia, including benign essential blepharospasm.[1]



C botulinum is a heterogeneous group of spore-forming, anaerobic, gram-positive microorganisms. Organisms of types A to G are distinguished by the antigenic specificities of their toxins. Eight distinct toxins have been described (ie, A, B, C1, C2, D, E, F, G).[2] In rare instances, a single strain of organism may produce more than one toxin. All toxins except C2 are neurotoxins; C2 is a cytotoxin of uncertain clinical significance. Toxin types A, B, E, and, in rare cases, F cause human disease; types C and D cause avian and nonhuman mammalian disease.[3]

Rarely, clostridial species other than C botulinum have been reported to cause disease, including rare toxin-forming strains of Clostridium butyricum and Clostridium baratii.

Clostridial spores are highly heat resistant, with inactivation requiring exposure to a temperature of 120°C. However, the toxin may be inactivated by exposure to a temperature of 100°C for 10 minutes.

Botulinum neurotoxins, whether directly ingested, produced in a C botulinum contaminated wound, or produced by C botulinum colonization within the intestines, enter the vascular system and are transported to peripheral cholinergic nerve terminals. The peripheral cholinergic nerve terminals involved include neuromuscular junctions, cholinergic parasympathetic nerve endings, and some peripheral ganglia. The toxin causes blockade of neuromuscular conduction by binding to receptor sites on presynaptic motor nerve terminals, entering the nerve terminal, and inhibiting the release of acetylcholine by proteolysis of components of the neurotransmitter exocytosis apparatus.

Blockade of neurotransmitter release at the nerve terminal is considered permanent. Evidence exists that the axon may sprout new terminals and allow recovery of neurotransmission.

Botulism is generally seen in 3 clinical scenarios, based on the mode of acquisition, as follows:

  • Food poisoning: This follows the ingestion of preformed toxins in food contaminated with C botulinum.
  • Wound infection: Infection of wounds by C botulinum most commonly occurs where wounds are contaminated heavily with soil or water. Spores may germinate into toxin-producing vegetative microorganisms.
  • Infant botulism: This results from intestinal colonization of organisms in infants younger than 1 year. [4, 5] The immature intestine system allows abnormal colonization. Toxin is produced in and absorbed from the gut, following ingestion of ingested spores. More recently, adult intestinal colonization botulism has been described in association with intestinal disease causing disturbance in normal intestinal flora.



United States

Overall, approximately 110 cases of botulism are reported annually in the United States.

Food-borne botulism is responsible for an average of 30 reported cases per year in the United States.[6] Since 1950, the average number of outbreaks per year is 9.4. In the United States, the geographic distribution of cases by toxin type generally coincides with the organism type found in the local environment. Toxin type A is the most predominant type west of the Rocky Mountains; type B generally is distributed but is more common in the eastern United States; while type E is found in the Great Lakes region and Alaska. In the United States, type A accounts for 60% of cases, type B 18%, and type E 22%. Home-processed foods are responsible for most outbreaks. Type E outbreaks are associated with fish products.

Infant botulism was first recognized as a disease in 1976. Infant botulism is responsible for about 60 cases each year; hence, it is now the most frequent form of the disease in the United States in recent years. Average annual incidence is approximately 1.9 per 100,000 live births. Mean age at onset is about 13 weeks but ranges from 1-63 weeks. Infant botulism is underrecognized and underreported.

Wound botulism is rare, with only several reports annually in the United States.


Human botulism occurs worldwide.

Food-borne botulism is responsible for almost 1000 cases worldwide each year.


Mortality and morbidity from botulism vary according to the mode of acquisition.

For food-borne disease with current medical supportive care, the US case-fatality rate for the period 1976-1984 was about 7.5%.[6] Type A disease is generally more severe than type B, with greater need for ventilatory support and longer disease course. The case-fatality rate for type A is about 10% and for type B is about 5%. Mortality from botulism is higher amongst patients older than 60 years compared to younger patients. The case-fatality rate for those older than 60 years was 30%. The average duration of pulmonary support for those requiring mechanical ventilation is 6-8 weeks. Some patients experience residual weakness and autonomic dysfunction for as long as 1 year.

The case-fatality rate for wound botulism is 10%. Survivors experience significant long-term morbidity.

Infant botulism has a case-fatality rate of 1.3%. Generally, symptoms progress for 2 weeks and then stabilize for 3 weeks, before recovery begins. The average length of infant inpatient hospital is about 4 weeks, although excretion of organisms may continue for several months after discharge, and a 5% relapse rate exists.


While no racial predilection exists, geographic distribution toxin type coincides with the organism type found in the local environment.


No sexual predilection exists.



Botulinum toxin binds irreversibly to the neuromuscular junction synapses. Neurologic recovery occurs when new motor endplates are regenerated, which may take weeks to months. Some symptoms of botulism may persist for as long as a year.

Intensive supportive care in the United States has improved the prognosis of botulism. Mortality has decreased from 60% in the 1950s to 5% overall today and less than 1% among those who are hospitalized. The fatality rate remains high in other parts of the world where supportive care is not available. Larger doses of ingested toxin results in higher morbidity and mortality rates. Mortality rates are also higher in type A than type B or C toxin disease.

Infants with botulism generally recover after 2-3 weeks, with most making gradual improvement over a period of 2 months.

Common complications include respiratory failure, which may require mechanical ventilation, and secondary infections such as pneumonia, urinary tract infection, and C difficile-associated colitis.


Patient Education

Transmission of toxin does not occur person-to-person, but meticulous handwashing is essential.

Soiled diapers of infants with botulism should be autoclaved because they can contain botulinum neurotoxin and spores. Spores can contaminate open skin lesions of caretakers, resulting in wound botulism. Caretakers with hand wounds should avoid handling soiled diapers.

Botulism must be reported immediately to the local state health department. This is important to obtain diagnostic aid, to determine appropriate collection and handling of specimens, and to obtain prompt antitoxin delivery.

Owing to the association of honey consumption with infant botulism, it has been suggested that honey should not be given to babies younger than 12 months.

Education about safe practices in food preparation and home-canning methods should be promoted. To kill C botulinum spores, a pressure cooker must be set to 116°C. Toxin destruction requires cooking of foods until their internal temperature is 85°C for 10 minutes. Bulging food containers should be discarded, as they may contain gas produced by C botulinum. Food that appears spoiled should be discarded.

Contributor Information and Disclosures

Bhupendra Patel, MD, FRCS Professor of Ophthalmic Plastic and Facial Cosmetic Surgery, Department of Ophthalmology and Visual Sciences, John A Moran Eye Center, University of Utah School of Medicine

Bhupendra Patel, MD, FRCS is a member of the following medical societies: American Academy of Ophthalmology, American Society of Ophthalmic Plastic and Reconstructive Surgery, Royal College of Surgeons of England, Royal Society of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

Andrew W Lawton, MD Neuro-Ophthalmology, Ochsner Health Services

Andrew W Lawton, MD is a member of the following medical societies: American Academy of Ophthalmology, Arkansas Medical Society, Southern Medical Association

Disclosure: Nothing to disclose.

Simon F Taylor, MBBS FRANZCO, FRACS, Clinical Senior Lecturer, Oculoplastic Surgery, Save Sight Institute, University of Sydney, Australia

Simon F Taylor, MBBS is a member of the following medical societies: Australian Medical Association, Royal Australasian College of Surgeons

Disclosure: Nothing to disclose.


Brian R Younge, MD Professor of Ophthalmology, Mayo Clinic School of Medicine

Brian R Younge, MD is a member of the following medical societies: American Medical Association, American Ophthalmological Society, and North American Neuro-Ophthalmology Society

Disclosure: Nothing to disclose.

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