Quantitative autonomic testing in the management of botulism

Abstract

Even with mild neurological signs, patients with botulism frequently complain of autonomic symptoms. This study aimed at the evaluation of sudomotor and cardiovascular reflex functions by quantitative autonomic testing (QAT), which may identify patients with autonomic involvement but otherwise benign clinical presentation. Five patients with food-borne botulism were subjected to a structured questionnaire on autonomic symptoms, cardiac and neurological examination, and QAT after a median of 2 weeks (baseline) and 12 weeks (follow-up) post intoxication. For calculation of haemodynamic and cardiovascular autonomic parameters, we used the Task Force((R)) Monitor (Version 2.1, CNSystems, Graz, Austria). Cardiovagal function was assessed by Ewing's test battery. Autonomic complaints were more pronounced than neurological symptoms. Baseline tests revealed widely abnormal sudomotor function and marked impairment of heart rate variation and blood pressure response to standing. Prominent features of cardiovascular failure were high resting heart rate, supine hypertension, orthostatic hypotension, and impaired baroreflex function. Three patients reported inability to keep up with their routine amount of physical work. Based on the baseline QAT results, these three patients were instructed to engage in physical activity but avoid physical strain until there was considerable improvement. On follow-up, fatigue was the most frequent residual complaint, sympathetic skin responses were present, and cardiovascular QAT results were significantly improved and did not differ from those of ten control subjects. QAT identified autonomic involvement in botulism patients with otherwise benign neurological presentation. Comprehensive evaluation of autonomic failure may provide useful information for the management of botulism.

Effects of onabotulinumtoxinA on cardiac function following intradetrusor injections

“…In line with that, animal studies in dogs demonstrated a significant reduction and even elimination of parasympathetic related bradycardia and atrial fibrillation, respectively, following botulinum toxin A injections into pericardial fat pads (Oh, et al, 2011, Tsuboi, et al, 2002. An attenuation of parasympathetic modulation on the heart has also been described in studies on the autonomic cardiac effects of botulism, reporting significant declines of parasympathetic test parameters that lasted longer than in sympathetic tests (Vita, et al, 1987), elevated resting heart rate, and LF/HF ratio (Topakian, et al, 2009).…”

“…Considering previous findings from studies on the effect of botulinum toxin on the cardiac autonomic function (Chen, et al, 1999, Claus, et al, 1995, Meichsner and Reichel, 2005, Pokushalov, et al, 2015, Reichel, et al, 1998, Topakian, et al, 2009, Vita, et al, 1987, effects seem to be predominantly HRV depressive, i.e. decrease in coefficient of variation of heart rate (Claus, et al, 1995), R-R interval variation (Chen, et al, 1999), RMSSD (Meichsner and Reichel, 2005, Pokushalov, et al, 2015, Reichel, et al, 1998, TP (Meichsner and Reichel, 2005), and SDNN (Meichsner and Reichel, 2005, Pokushalov, et al, 2015, Vita, et al, 1987, and/or parasympatholytic (Dickson andShevky, 1923, Rosenblum, 1966), i.e.…”

“…decrease in coefficient of variation of heart rate (Claus, et al, 1995), R-R interval variation (Chen, et al, 1999), RMSSD (Meichsner and Reichel, 2005, Pokushalov, et al, 2015, Reichel, et al, 1998, TP (Meichsner and Reichel, 2005), and SDNN (Meichsner and Reichel, 2005, Pokushalov, et al, 2015, Vita, et al, 1987, and/or parasympatholytic (Dickson andShevky, 1923, Rosenblum, 1966), i.e. increase in resting heart rate (Meichsner and Reichel, 2005, Pokushalov, et al, 2015, Reichel, et al, 1998, Topakian, et al, 2009) and decrease of parasympathetic related test outcomes such as 30:15 ratio (Topakian, et al, 2009, Vita, et al, 1987, E/I ratio (Meichsner and Reichel, 2005, Topakian, et al, 2009, Vita, et al, 1987, and Valsava ratio (Topakian, et al, 2009, Vita, et al, 1987. In line with that, animal studies in dogs demonstrated a significant reduction and even elimination of parasympathetic related bradycardia and atrial fibrillation, respectively, following botulinum toxin A injections into pericardial fat pads (Oh, et al, 2011, Tsuboi, et al, 2002.…”

Takotsubo-like Myocardial Dysfunction in a Patient with Botulism

“…To our knowledge, this is the first case of Takotsubo-like myocardial dysfunction in a patient with botulism; however, we believe that this condition has likely also been observed previously in studies on autonomic dysfunction due to botulism ( 3 ). Autonomic failure due to botulism had been considered to account for some cases of sudden infant death syndrome ( 4 ) as well as arrhythmias and electrocardiographic changes in adults ( 5 ).…”

Foodborne botulism due to ingestion of home-canned green beans: two case reports

“…Both autonomic symptoms can be explained by an inhibition of the cholinergic parasympathetic nervous system. Autonomic symptoms due to botulinum toxin poisoning, including high resting heart rate, supine hypertension, orthostatic hypotension, and impaired baroreflex function were reported even in mild clinical courses [ 12 ]. Moreover, autonomic dysfunction can be the leading symptom of botulism type B [ 13 ].…”