Long-Term Outcomes of 217 Botulism Cases in the Republic of Georgia

Abstract

Background. The acute paralytic syndrome of botulism has been well-described; however, little is known about its long-term consequences.Methods. We conducted a case-control study in the Republic of Georgia to evaluate the health of patients у6 months after they had experienced an episode of botulism. Case patients were selected on the basis of who had had a clinical diagnosis of foodborne botulism reported to the national surveillance system from 1998 through 2003. Three control subjects were randomly selected from each patient's community.Results. We located 217 patients who had had botulism from surveillance records, with a median time since onset of illness of 4.3 years. The median age was 37 years, and 49% of the patients were female, similar to the control subjects. Most of the patients (68%) had acquired botulism from home-conserved vegetables (probably containing toxin type B), 15% had been hospitalized for 11 month, and 25% had required mechanical ventilation. Six patients died. Of the remaining 211 patients, 68% reported having worse health at the time of the interview than 6 years before the interview, compared with 17% of 656 control subjects (matched odds ratio, 17.6; 95% confidence interval, 10.9-28.4). Overall, 49% of the patients reported their current health as "fair" or "poor," versus 25% of the control subjects (odds ratio, 5.0; 95% confidence interval, 3.2-7.6). Patients were more likely than control subjects to report fatigue, weakness, dizziness, dry mouth, and difficulty lifting objects ( , for P ! .05 each). Patients were more likely than control subjects to report difficulty breathing caused by moderate exertion ( ) but not by minimal exertion or at rest. Patients were also more likely to report being limited in vigorous P ! .001 activities, walking 3 blocks, and climbing 3 flights of stairs ( , for each). Finally, patients reported feeling P ! .05 significantly worse than control subjects for 6 of 11 questions regarding psychosocial well-being ( , for each). P ! .05 In a multivariable model involving patients who had had botulism, mechanical ventilation during acute illness, older age, and region of residence independently predicted worse health.Conclusions. Several years after acute botulism, patients reported significant health, functional, and psychosocial limitations that are likely to be consequences of the illness.

Quantitative autonomic testing in the management of botulism

“…Neurological recovery is often complete, but in severe cases secondary changes such as critically illness neuropathy and myopathy patients may result in late symptoms [7]. Neurological symptoms may be outlasted by general fatigue [3,7,20]. In our patients, fatigue was the most frequent complaint on follow-up.…”

“…At the neuromuscular junctions, this blockade is overcome by enlargement of the junctions and sprouting of nerve terminals, which takes weeks to months [3]. Neurological recovery is often complete, but in severe cases secondary changes such as critically illness neuropathy and myopathy patients may result in late symptoms [7]. Neurological symptoms may be outlasted by general fatigue [3,7,20].…”

“…In this context it is remarkable that a recent case-control study by Gottlieb et al [7] on the long-term outcome of 217 botulism patients showed that several years after the infection a substantial number of patients was still reporting dry mouth, fatigue, limitation in vigorous activities and other complaints. The authors concluded that, rather than relying on subjective perception of symptoms, measurement of functional status with objective characterisation of symptoms could help to better define and prevent the longterm consequences of botulism [7].…”

Muscle biopsy substantiates long‐term MRI alterations one year after a single dose of botulinum toxin injected into the lateral gastrocnemius muscle of healthy volunteers

“…This prolonged atrophy has been reported previously using electromyographic examinations 16 and from patients surviving botulism. 50 It should be considered when repeated BoNT/A injections are performed into the same muscles because of the vanishing clinical effect after 3-6 (-12) months according to the standard schedule. 1,3,28 In conclusion, persistence of denervation atrophy with evidence of incomplete reinnervation was, for the first time, documented using repeated MR-morphometry of the GCL muscle in two healthy volunteers up to 12 months after a single dose of BoNT/A injection, and confirmed by a muscle biopsy using enzyme histochemistry and electron microscopy 12 months after injection.…”

Making the Best of the Evidence: Toward National Clinical Guidelines for Botulism

“…Thorough, standardized real-time assessment of patients starting as soon as possible in the course of botulism could refine our understanding of early presentation and the frequency of variations of the classic symptoms. Prospective assessment of patients over months or years could better define long-term complications, some of which are subtle [27]. Prospective standardized evaluation would also expand our limited understanding of botulism and its treatment in children and pregnant women.…”