SALIENT FEATURES HISTORICAL DATA

21 YEAR OLD , FEMALE

BIRTHDAY CELEBRATION IN A FARM

CANNED VEGETABLES

SALIENT FEATURES SYMPTOMS

PROGRESSIVE BLURRING OF VISION

NAUSEA AND VOMITING

DIFFICULTY SPEAKING AND SWALLOWING

GENERALIZED BODY WEAKNESS

SALIENT FEATURES SIGNS

PTOSIS

SALIENT FEATURES

SALIENT FEATURES SIGNS

OPTHALMOPLEGIA (EXTERNAL & INTERNAL)

PTOSIS

FACIAL WEAKNESS

DEPRESSED REFLEXES

RESPIRATRY DISTRESS

IS THERE A NEUROLOGIC PROBLEM? A. SIGNS OF MENINGEAL IRRITATION

NO NUCHAL RIGIDITY

B. SIGNS OF INCREASED INTRACRANIAL PRESSURE?

(-) HEADACHE

(-) DEPRESSION IN THE LEVEL OF CONSCIOUSNESS

(-) DIPLOPIA

(+) VOMITING

IS THERE A NEUROLOGIC PROBLEM? C. PRESENCE OF FOCAL NEUROLOGIC DEFICITS

1. WEAKNESS: GENERALIZED

DESCENDING TYPE

2. HYPOACTIVE REFLEXES

IS THERE A NEUROLOGIC PROBLEM

WEAKNESS PLUS HYPOACTIVE

REFLEXES NEGATIVE BABINSKI

LOWER MOTOR NEURON TYPE OF WEAKNESS

VHC

SPINAL OR PERIPHER

AL

NERVE

NMJ MUSCLE

LMN LESION

NMJ

• BULBAR INVOLVEMENT

NMJ

• FLUCTUATING WEAKNESS

NMJ

• ABSENT SENSORY • MANIFESTATIONS

PRE SYNAPTIC

SYNAPTIC POST SYNAPTIC

BOTULISM INSECTISIDES

MYASTHENIA GRAVIS

LAMBERT EATON MYASTHENIC SYNDROME

SNAKE VENOM TOXIN

ACUTE PATTERN

OF WEAKNESS

FOOD EXPOSURE

BOTULINUM TOXICITY

PRESYNAPTIC NMJ BOTULISM LEMS FACIAL WEAKNESS

OPHTHALMOPARESIS

SPEECH/ SWALLOWING IMPAIRMENT

DRY MUCOSA

IMPAIRED PUPILLARY CONSTRICTION

TRUNCAL AND LIMB WEAKNESS

NORMAL PUPILS

FOODBORNE BOTULISM DISEASE MECHANISM: INGESTION OF TOXIN

ABSORPTION

STOMACH :NOT ABSORBED; TOXIN COMPLEX (ASSOCIATED PROTEIN) RESISTANT TO PROTEOLYSIS

INTESTINE:

ALKALINE pH INTESTINE DISSOCIATES TOXIN FROM ASSOCIATED PROTEIN

DISSOCIATED TOXIN IS ABSORBED

BOTULINUM TOXIN COMPLEX ( PROTOXIN + AUXILIARY PROTEIN)

CLEAVAGE OF PROTOXIN

1. HEAVY CHAIN

A.C TERMINAL - BINDING TO TARGET

B. N TERMINAL – TRANSLOCATE L CHAIN

2. LIGHT CHAIN

ZINC DEPENDENT ENDOPEPTIDASE

CLEAVE PROTEINS FORMING SYNAPTIC VESICLE FUSION AND DOCKING COMPLEX

PATH OF TOXIN 1. PASSAGE OF TOXIN FROM GI TRACT TO

VASCULATURE

A. ABILITY TO CROSS CELLS- TYPE A&B

B. C TERMINUS OF HEAVY CHAIN

2. TOXIN PASSES OUT OF VASCULATURE TO PRESYNAPTIC REGIONS

DOES NOT CROSS BBB

PATH OF TOXIN STEPS IN DEVELOPMENT OF PRESYNAPTIC

BLOCKADE

1. BINDING TO RECEPTORS ON UNMYELINATED PRESYNAPTIC MEMBRANE (DOUBLE RECEPTOR)

2. UPTAKE OF TOXIN INTO NERVE TERMINALS BY ENDOCYTOSIS

3. TRANSLOCATION TO CYTOSOL

4. INHIBITION OF TRANSMITTER EXOCYTOSIS FROM PRESYNAPTIC TERMINAL

PATH OF TOXIN 4.INHIBITION OF TRANSMITTER EXOCYTOSIS

BLOCK NT RELEASE AT PERIPHERAL CHOLINERGIC NERVE TERMINALS

NEUROMUSCULAR JUNCTION

AUTONOMIC NERVE TERMINALS

SYMPATHETIC AND PARASYMPATHETIC

PATH OF TOXIN 4.INHIBITION OF TRANSMITTER EXOCYTOSIS

BLOCK NT RELEASE AT PERIPHERAL CHOLINERGIC NERVE TERMINALS

NEUROMUSCULAR JUNCTION

AUTONOMIC NERVE TERMINALS

SYMPATHETIC AND PARASYMPATHETIC

BOTULISM DIAGNOSIS 1. ELECTROPHYSIOLOGICAL STUDY

a. REDUCED CMAP AMPLITUDE IN AT LEAST 2 MUSCLES

b. AT LEAST 20% FACILITATION OF CMAP AMPLITUDE DURING TETANIC STIMULATION

INCREMENTAL RESPONSE

c. PERSISTENCE OF FACILITATION FOR AT LEAST 2 MINUTES AFTER ACTIVATION

d. NO POSTACTIVATION EXHAUSTION

JOLLY TESTING

HYPOTHENAR MUSCLES

DECREMENT

INCREMENT

BOTULISM DIAGNOSIS 2. ELECTROMYOGRAM

MUSCLE DENERVATION

FIBRILLATION AND POSITIVE SHARP WAVES

FIBRILLATION

POSITIVE SHARP WAVE

FASCICULATION

BOTULISM DIAGNOSIS 3. ANALYSIS OF SERUM, FECES AND IMPLICATED

FOOD

MOUSE TOXICITY ASSAY

ELISA TEST FOR RAPID SCREENING

END PLATE ELECTROPHYSIOLOGY MEPP FREQUENCY : REDUCED

EPP QUANTAL CONTENT : REDUCED