eMedicine Specialties > Emergency Medicine > Warfare - Chemical, Biological, Radiological, Nuclear and Explosives

CBRNE - Botulism: Differential Diagnoses & Workup

Author: Peter P Taillac, MD, Associate Clinical Professor of Surgery, Division of Emergency Medicine, University of Utah Health Sciences Center
Coauthor(s): Joseph Kim, MD, Chairman, Department of Emergency Medicine, Western Medical Center; Clinical Instructor, University of California at Irvine
Contributor Information and Disclosures

Updated: Apr 10, 2008

Differential Diagnoses

Diphtheria
Encephalitis
Guillain-Barré Syndrome
Hypermagnesemia
Lambert-Eaton Myasthenic Syndrome
Myasthenia Gravis

Other Problems to Be Considered

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

Workup

Laboratory 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.

More on CBRNE - Botulism

Overview: CBRNE - Botulism
Differential Diagnoses & Workup: CBRNE - Botulism
Treatment & Medication: CBRNE - Botulism
Follow-up: CBRNE - Botulism
Multimedia: CBRNE - Botulism
References
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References

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  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].

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Further Reading

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Keywords

botulism, Clostridium botulinum, C botulinum, Clostridium butyricum, C butyricum, Clostridium baratii, C baratii, neurotoxin, botulinum toxin, bioweapon, terrorist attack, biowarfare agent

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Contributor Information and Disclosures

Author

Peter P Taillac, MD, Associate Clinical Professor of Surgery, Division of Emergency Medicine, University of Utah Health Sciences Center
Peter P Taillac, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Joseph Kim, MD, Chairman, Department of Emergency Medicine, Western Medical Center; Clinical Instructor, University of California at Irvine
Disclosure: Nothing to disclose.

Medical Editor

Edward Bessman, MD, Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University
Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Barry J Sheridan, DO, Chief, Department of Emergency Medical Services, Brooke Army Medical Center
Barry J Sheridan, DO is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Robert G Darling, MD, FACEP, Clinical Assistant Professor of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine; Associate Director, Center for Disaster and Humanitarian Assistance Medicine
Robert G Darling, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, and Association of Military Surgeons of the US
Disclosure: Nothing to disclose.

 
 
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