Сlinical and epidemiological characteristics of botulism

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Introduction. Infectious diseases play a significant role in human pathology. Unlike somatic diseases, some dangerous infectious diseases with a high epidemic potential are capable of global spread, are unpredictable, and real control over them is a big problem [1].
The problem of food poisoning is relevant for practical health care. Despite the control carried out at the stages of production and sale of food products, there are still a lot of opportunities for their contamination. The most severe food poisoning of bacterial nature is botulism, which is characterized mainly by a severe course and high mortality. In Russia, botulism is registered in the form of sporadic, less often – group diseases and accounts for about 300 cases per year. Recently, there has been an increase in deaths from botulism, which causes special attention to this infection. Usually, diseases occur when eating products in which there were conditions for the development of vegetative forms of microbes and toxin formation. In our country, botulism diseases are more often associated with the use of home-canned mushrooms, smoked, salted or dried fish [2, 3].
Every year, tens of thousands of cases of the disease are registered in the world, but the true incidence is much higher. Outbreaks often occur when eating certain home-made products, but there are also known group diseases when eating products that were produced at large food enterprises [4].
Botulism is an acute infectious disease from the group of saprozoonoses with a fecal-oral transmission mechanism, which develops as a result of the use of food products in which there was an accumulation of botulinum toxin. Depending on the antigenic properties, 8 serovars of Botulinum bacillus are isolated (A, B, C1, C2, D, E, F, G). On the territory of Russia, the disease is caused by serovars A, B and E. The mortality rate in severe forms of the disease is 15-50%. Botulism also has a toxic effect when inhaled and through the mucous membranes of the eyes [5, 6].
symptoms of botulism were first described in the medical literature in the late xvii-early xviii century. the first outbreaks of the disease among people were associated with the use of blood and liver sausages. In the future, similar symptoms of the disease were also observed in people who consumed smoked ham, salted fish, canned vegetables and home-made meat products [7].
The course of botulism can be uncomplicated and complicated. The most common secondary bacterial complications are aspiration pneumonia, atelectasis, purulent tracheobronchitis. in addition, there are: specific and iatrogenic complications [8-13].
The severe course of the disease with long periods of hospital stay does not allow us to attribute the problem of botulism to a number of secondary ones. cases of the disease are associated with the widespread popularity of home canning [14].
A person becomes infected with botulism when eating pathogens infected with spores in most cases, home canning. Hospitalization of patients with botulism is mandatory, even if the presence of this pathology is suspected. Patients are sent to any hospital where there is a ventilator. In the clinical course of the disease, there are three main syndromes: dyspeptic disorders, visual or respiratory disorders. To neutralize the toxin circulating in the blood, a polyvalent anti-botulinum serum is administered. At the same time, detoxification therapy is carried out, and the appointment of antibacterial therapy is also recommended [15].
There are four types of botulism: food, wound, child and intestinal colonization. Among them, food botulism is of the greatest importance for public health, since this form of the disease can have an epidemic character. Food-borne botulism occurs as a result of eating food containing botulinum toxin, the most powerful biological toxin known to humans. In most cases of foodborne botulism, three types of neurotoxins (A, B, and E) are the cause. Clostridium Botulinum spores are ubiquitous in the soil and easily contaminate food, but they acquire the ability to grow and produce a toxin only under rare circumstances, including an anaerobic environment with a low concentration of salt, sugar and acid [16].
The purpose of the study. To give a clinical and epidemiological description of botulism in the Astrakhan region for the period from 2013 to 2019.
Materials and Methods. The clinical picture of botulism was studied on the basis of the analysis of the case histories of 37 patients (26 (70.3%) men and 11 (29.7%) women) diagnosed with Botulism, who were treated at the Regional Infectious Clinical Hospital named after A.M. Nichogi in Astrakhan from 2013 to 2019. The patients were mainly young and middle – aged: from 21 to 40 years – 15 (40.5%) people, over 60 years – 11 (29.7%) people (Table 1). The share of urban residents was 27 (73%) people, rural-10 (27%) people. a person.
Table 1. Distribution of patients with botulism by age, years
The age of patients, the Number of cases %
21–30 7 18,9
31–40 8 21,6
41–50 5 13,5
51–60 6 16.2
61–75 11 29,7

Statistical processing of the results was carried out using Microsoft Office Excel and biostat Professional 5.8.4. The percentage expression of the data series was determined.

Results and discussion. It is established that up to 10 cases of botulism are registered annually in the Astrakhan region. During the study period, the mortality rate was 3 (8.1%) people, including 2 people in 2013 and 1 person in 2015 (Table 2).

Table 2. Incidence of botulism and mortality from it
in the Astrakhan region
Year Number of patients Number of deaths
2013 6 2
2014 5 0
2015 5 1
2016 10 0
2017 1 0
2018 6 0
2019 4 0
total 37 3

botulism was recorded sporadically and only in 3 cases there was a group incidence among family members (father and son, mother and son, father and daughter). The disease was diagnosed during the year, but more often in winter and spring (25 (67.6%) cases). During this period, the population most often uses canned vegetables and mushrooms.
When carefully collecting an epidemiological history for the incubation period, which can be from several hours to 7-10 days, the following causes of infection with botulism were identified. Thus, most often (28 (75.7%) cases) patients indicated the use of canned home-made products. Canned vegetables (cucumbers, tomatoes, vegetable salad, eggplant, cabbage) were consumed by 18 (48.7%) people, mushrooms – 10 (27.0%), dried fish – 7 (18.9%), herring-balyk – 1 (2.7%), home – made liver pate-1 (2.7%) patient.
Emergency doctors delivered 24 (64.9%) patients with botulism to the hospital. According to the direction of the polyclinic doctors, 11 (29.7%) patients were hospitalized, 2 (5.4%) patients were transferred from the neurological hospital of the city clinical Hospital No. 3, where they were treated with acute cerebral circulation disorders.
the incubation period in the observed patients averaged 2.4 days. the incubation period in 3 patients with severe botulism lasted 12, 18 and 20 hours. in 24 (64.9%) patients, the incubation period lasted 1-2 days, in 12 (32.4%) patients 3-5 days and in 1 (2.7%) patient – 6 days. terms of hospitalization of patients in the hospital: in the first 3 days, 26 (70.3%) patients were hospitalized, on day 4-5 – 8 (23.8%) patients, on day 6-7 – 3 (8.1%) patients. Directional diagnoses were as follows: botulism - in 32 (86.5%) patients, food toxicoinfection – in 4 (10.8%), gastroenteritis – in 1 (2.7%). all patients were diagnosed with botulism when they were admitted to the emergency department of the infectious diseases hospital.
according to the severity of the condition, 17 (45.9%) patients were hospitalized in the intensive care unit (icu). severe course of the disease was in 17 (45.9%) patients, moderate-in 20 (54.1%) patients.
The disease developed gradually. An increase in body temperature in botulism is not characteristic. In 16 (43.2%) cases, there was a short-term increase in temperature to subfebrile figures. Early and persistent symptoms in the observed patients were severe muscle weakness (100%), dizziness (78.4%), difficulty walking and unsteadiness of gait (83.8%). In 34 (91.9%) patients, the most pronounced were ophthalmoplegic symptoms: blurred vision, fog, "flies" in front of the eyes, inability to read the text. Diplopia was observed in 32 (86.5%) patients, bilateral ptosis-in 26 (70.3%) patients, mydriasis – in 27 (73%) patients. The reaction of the pupils to light was absent in 13 (35.1%) patients, in isolated cases anisocoria was noted. Limited mobility of the eyeballs was observed in 26 (70.3%) patients, strobismus (strabismus) - in 8 (21.6%) patients. There was no sensitivity disorder.
Along with ocular symptoms, symptoms due to damage to the IX and XII pairs of cranial nerves appeared early. Hoarseness of voice, nasal tone of voice-nasal twang were in 21 (56.8%) patients, slurred, blurred speech – in 14 (37.8%) patients. Due to paresis of the muscles of the pharynx and soft palate, 22 (59.5%) patients had difficulty swallowing solid food, a feeling of coma in the throat. Choking, liquid food and water were poured through the nose in 13 (35.1%) patients. Pharyngeal reflex was absent or decreased in 29 (78.4%) cases. Constant symptoms in patients with botulism were dry mouth and thirst (100%).
Gastroenteritis syndrome was detected in some patients, it was short-lived and quickly replaced by neurological symptoms. Pain, a feeling of heaviness in the epigastric region were in 16 (43.2%) patients, nausea – in 29 (78.4%), vomiting – in 15 (40.5%), (once – in 6 cases, repeated – in 9 cases). Loose stools up to 3-4 times were present in 11 (29.7%) patients and lasted 1-2 days. 70.3% of patients had prolonged stool retention. In 25 (67.6%) patients, flatulence associated with intestinal paresis was detected.
It is known that the involvement of large motor neurons of the spinal cord and medulla oblongata in the pathological process leads to damage to the respiratory muscles and diaphragm. evidence of this was that patients complained of a feeling of compression and compression in the chest. In some patients, the cough reflex disappeared. Dyspnea was observed in 17 (45.9 %) patients. Given that respiratory distress and respiratory arrest are one of the main causes of death in patients with botulism, 10 (27%) patients in the ICU, due to the development of acute respiratory failure (ODN) of the third degree and a decrease in oxygen saturation below 90% were transferred to artificial ventilation (IVL). The duration of the ventilator was from 7 to 28 days.
since botulism is accompanied by functional disorders of the circulatory system, the heart tones in all patients were muted. At the beginning of the disease, most patients had bradycardia, and then in severe cases, 18 (48.6%) patients developed tachycardia. In the first days of the disease, 14 (37.8%) patients had an increase in blood pressure. Hypotension was observed in 7 (18.9%) patients. All symptoms of botulism in patients developed against the background of clear consciousness.

Complications in the observed patients were as follows: pneumonia - in 11 (29.7%) patients, myocarditis-in 7 (18.9%) patients, edema-swelling of the brain – in 3 (8.1%) patients, multiple organ failure – in 3 (8.1%) deceased patients.
Concomitant diseases were observed in 18 (48.6%) patients: in 11 (29.7%) patients – atherosclerosis of the aorta, cerebral vessels, heart, secondary hypertension; in 3 (8.1%) patients – diabetes mellitus; in 13 (35.1%) patients – ischemic heart disease, chronic heart failure; in 1 (2.7%) patient – pneumothorax. We observed a patient with severe botulism, who had a pregnancy of 32 weeks. The patient was on a ventilator. There was a premature emergency delivery. The child was born without pathology. The mother's illness ended in recovery.
Patients with botulism received the following treatment. Regardless of the time of admission of patients to the hospital, a thorough gastric lavage (through a probe) with a 3% solution of sodium bicarbonate and intestines (siphon enema) was performed. In patients with severe botulism, gastric lavage was performed through a nasogastric tube. Monovalent anti-botulinum antitoxic serum was immediately administered: type A and E 10,000 IU; type B-5000 IU. The serum was administered to 200 ml of isotonic sodium chloride solution intravenously. prednisone 60-90 mg was administered intravenously before serum administration.
For the purpose of etiotropic therapy, patients were prescribed levomycetin 0.5 g 4 times a day or levomycetin-sodium succinate 1 g 3 times a day intravenously for 7-10 days. Detoxification therapy was carried out with the introduction of crystalloids and colloids, diuretics. In addition, cardiovascular agents, B vitamins, 5% prozerin solution of 1 ml subcutaneously 3-4 times a day were used. With the development of pneumonia, broad-spectrum antibiotics were prescribed: cephalosporins of the III-IV generation, fluoroquinolones, etc. Patients with swallowing disorder were provided with probe and parenteral nutrition. With the development of odn iii-degree, a ventilator was performed.
34 (91.9%) patients with botulism recovered. In 3 (8.1%) cases, the disease was fatal. The average bed-DAY IN PATIENTS with botulism was 20.1.
Conclusions
1. In the Astrakhan region, the incidence of botulism is recorded annually up to 10 cases per year.
2.Almost half of the patients (45.9%) have severe botulism.
3. The disease is mostly sporadic and is associated with the use of canned vegetables and home-made mushrooms. In the Astrakhan region, cases of botulism associated with the use of dried fish have become more frequent.
4. Late hospitalization was observed in 1/3 of patients with botulism, which is associated with late diagnosis at the prehospital stage and late access to medical care.

About the authors

Lelya P. Cherenova

Astrakhan State Medical University

Author for correspondence.
Email: cherenovalp@mail.ru

Сandidate of medical sciences

Russian Federation, Astrakhan

Anna V. Matsuy

Regional Infectious Clinical Hospital Named A.M. Nichogi

Email: gpg222@mail.ru

Head of department

Russian Federation, Astrakhan

Igor V. Cherenov

Specialized Clinical Children’s Infectious Diseases Hospital

Email: cherenovigor76@mail.ru

Сandidate of medical sciences

Russian Federation, Krasnodar

References

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