Foodborne Botulism or… Please don’t pass the olives! Unusual cases of food poisoning. Corinne...

Foodborne Botulism or…Please don’t pass the olives! Unusualcases of food poisoning.

Corinne Amar PhDHead of the foodborne pathogens reference services FPRS,Gastrointestinal Bacteria Reference Unit GBRU

2 Foodborne botulism

Botulism• Rare but potentially fatal disease that causes paralysis• Caused by neurotoxins of Clostridium botulinum and by rare

strains of C. baratii and C. butyricum.• Botulism affect humans and other animals


A bit of history• Botulism first recorded in Europe in 1735 and that was suspected of being

associated with a German sausage. It was named after the Latin word for sausage, ''botulus’’

• 1817: first publication of outbreak reports

• In 1895, a botulism outbreak (34 cases) after a funeral dinner with smoked ham in the small Belgian village of Ellezelles led to the isolation of the pathogen Clostridium botulinum by Emile Pierre van Ermengem, bacteriologist at the University of Ghent.

Johann von Autenrieth1752-1832

Emile Pierre van Ermengem 1851 – 1922 or 1932


The Hotel Loch Maree tragedy First recorded outbreak of botulism in the UK.

Summer 1922: a group of Londoners, staying at the hotel ordered their meal to be prepared in advance.Potted duck had been on the menu all summer and on the 14th August, the last of the duck meat from the glass jar was scrapped to make sandwiches which were wrapped for a picnic.

All 8 people ate the sandwiches.

By following morning they were all ill.

72h later, 6 people were dead and the other 2 died within the next 5 days.

Bruce White from University of Bristol isolated Clostridium ‘botulinus’ from remainder of one sandwich.


Clostridium botulinumOrganism exists in the natural environment as resistant spores in soil, sediment, mud, water. Under the right conditions (anaerobic) spores germinate, multiply and produce toxin

Botulism Neurotoxin or BoNT can also be produced by rare strains of C. butyricum and C. baratii

• Gram positive rod

• Strictly anaerobe

• Six antigenically distinct neurotoxins A to G

• Types A, B, E and F associated with human disease,

• Types C and D animal disease, G no disease


Four distinct groups of organisms by phenotypic characteristics and DNA homology – human disease groups I, II

Group I (proteolytic activity)

Group II (non proteolytic)

Toxin types A, B, F B, E, F

Minimum growth temperature 10 3.3

Optimum growth temperature 35-40 18-25

D 100ºC (spores) 25 minutes <0.1 minutes

D 121ºC (spores) 0.1-0.2 minutes <0.001 minutes

Minimum pH for growth 4.6 5

[Inhibitory salt] (%) 10 5


Forms of botulism:• Foodborne botulism

• Infant botulism

(main form of botulism at present in the UK)

• Wound botulism

• Accidental or deliberate release


Foodborne botulism• Intoxication

• by ingestion of preformed toxin in food where the organism has grown


Infant botulism• Toxico infection

• By ingestion of spores which germinate, multiply and produce toxin in the gut: gut colonisation by the organism

• Usually occurs in infants <1 year


Wound botulismWound infection where the bacterium multiplies under anaerobic conditions and produces toxin

Exclusive to illegal injection of drugs in the UK but reported in other patient groups elsewhere


Accidental/ deliberate release•Cosmetic or therapeutic

•Bioterrorism – C. botulinum is a schedule 5 organism


Mechanism of action of the botulism neurotoxin


SymptomsA rapidly progressive descending symmetrical paralysis

Foodborne/ wound botulism• Possible D and V• Diplopia• dysphagia or dysarthria• dry mouth• Hypotension• Urinary retention, or

constipation.• Respiratory failure, Cardiac

arrest• Diminished or absent deep

tendon reflexes

Infant BotulismLess specific:• Constipation, irritability followed

by Lethargy• Poor feeding• Poor sucking• Drooling• Hypotonia• General weakness

not usually present: elevated blood pressure ; fever; altered mental state; altered sensation;


Differential diagnosis:Myasthenia gravis: Tensilon test positive

Guillain-Barre syndrome: Ascending paralysis, CSF protein elevated

Miller-Fisher Syndrome Descending paralysisPresence of anti-ganglioside antibodies:CSF protein elevated.


Laboratory confirmation of botulismBotulism is a Clinical Diagnosis

Detection of toxin

Food, serum, faeces, rectal wash

M.B.A.

Detection of toxin genes A,B,E, FFood, faeces, rectal wash, pus, tissue

Real time PCR

Culture and isolation of C. botulinum

Food, faeces, rectal wash out, wound tissue, pus, environmental samples

Detection of the organism by:


Specimens to send to the reference laboratory (Colindale)

Foodborne botulism:Toxin detection by MBA:• Serum (2-10ml) NOT haemolysed – NOT plasma• Stool and others (vomitus, gastric contents, intestinal contents)• Food frozen except for tins and jars

Detection of the organism by toxin gene detection (PCR) and culture:• Stool in anaerobic broth (ex: CMB – Robinson – FAB)• Food• Others – vomitus, gastric contents…in anaerobic broth


Specimens to send to the reference laboratory (Colindale)

Infant botulismDetection of the organism by toxin gene detection (PCR) and culture:• Stool or rectal wash out in anaerobic broth• Food (honey)• Dust and environment samples (water sediment – pet food)

Toxin detection:• Stool• Rarely: serum


Wound botulismToxin detection:• Serum (2-10ml)

Detection of the organism by toxin gene detection (PCR) and culture:• Pus, debrided tissue in anaerobic broth• Heroin

Specimens to send to the reference laboratory (colindale)


Timing of specimens is importantSerum: within 2 days of onset of symptomsNeurotoxin detected in serum and faeces

>50% within 1 day of onset<25% of cases after 3 days

Faeces: within a week of onset:C. botulinum detected in faeces

>70% within 2 days40% after 10 days

Immunity to botulism does not develop, even with severe disease – repeated occurrence of botulism has been reported.


Foodborne botulism in the UK and Ireland 1922-1989Year Cases Deaths Food Toxin type

1922 8 8 Duck pate A

1932 2 1 Home made rabbit and pigeon broth NK

1934 1 0 Home made jugged hare NK

1935 ?5 ?4 Home made nut brawn A

1935 1 1 Home made minced meat pie B

1949 5 1 Home made macaroni cheese NK

1955 2 0 Pickled fish A

1978 4 2 Canned salmon E

1987 1 0 Airline meal (rice and veg) A

1989 27 1 Hazelnut yoghurt B


Foodborne botulism in the UK and Ireland, 1998-2011Year Cases Food Preparation and origin Toxin type

1998 2 Bottled mushrooms Home made in Italy B

2003 1 Sausage Home made in Poland B

2004 1 Hummus Commercial, UK Not confirmed

2005 1 Not known returned from Georgia A

2005 1 Preserved pork Home made in Poland B

2006 1 Preserved pork Home made in Poland A/B

2008 1 Polish sausages Polish national in Ireland B

2010 1 Not known Returned from Algeria B

2011 3 Korma sauce Commercially prepared, UK A

2012 1 Olives From Italy, distributed in Europe B


Foodborne botulism July 2012 - Olives14th July: A 46 year old female Oxfordshire resident has a lunch/dinner party at friends.

15th July: she developed mild symptoms of blurred vision, dry mouth.

18th July: she goes to her GP who takes a blood specimen.

19th July: Admitted to hospital, seen by neurologist on the 20th when the patient developed poor swallowing – the neurologist suggests botulism as diagnosis.

The patient is monitored – not ventilated

Cranial bilateral bulbar palsy

Proximal upper limb weakness

No sensory loss


Foodborne botulism July 2012 - Olives1 week after onset of symptoms…

22nd July: Hospital contacts duty doctor in Colindale for obtaining antitoxins.

23rd July: Reference laboratory contacted by duty doctor.

Follow a series of phone calls between Reference laboratory and the hospital – consultant micro, the ITU and Thames Valley HPU.


Foodborne botulism July 2012 - OlivesThe patient ate at the party. She was the only one with symptoms and the only one to have eaten olives at the party. Another guest spat out an olive saying it did not taste right.

The olives were then put aside to be disposed of, but stay on a table at room temperature while the hosts went for a week abroad on holiday.

When the host came back, they learned their friend was ill, called the hospital and suggested the olives was the cause of illness.


Foodborne botulism July 2012 - Olives

23rd July, at 17:20The olives arrived at Colindale.

• The original jar with olives – pH 6.65• A sterile container with olives (the original was leaking)• A CMB with a rectal swab DOC 22.07.12 – 7 days after onset of symptoms• Serum DOC 18.07.12 taken by GP – 3 days after onset of symptoms• Serum DOC 22.07.12 – pre-IG treatment – 7 days after onset of symptoms


Foodborne botulism July 2012 - Olives24th July,

The olives:10:30 - PCR results – POSITIVE for neurotoxin gene B11:30 – MBA results – POSITIVE for typical symptoms of botulism (neutralisation tests were performed the next day and detected neurotoxin B)

The clinical specimens:• Rectal swab - negative• Serum – negative

FSA alerted National recall of olives and warming

not to eat from this batch


Foodborne botulism July 2012 - Olives

25th July, 10 days after onset of symptoms, a faecal specimen is collected from the patient, now at home.

27th July, Friday:

A stool specimen arrived at Colindale. It can not be tested on receipt because it is not in a broth.

Broth inoculated with the stool specimen – incubated overnight

30th July Monday:

PCR results – POSITIVE for neurotoxin gene B


Foodborne botulism - Scotland 20118th November:

A 5 year old child developed diplopia and dysphagia – taken to GP who sent the child back home.During the night, child became very unwell, unable to swallow, drooling, taken to GP again then to hospital in Sterling.Child had to be ventilated and was taken to Children’s Hospital PICU in Glasgow.On same day in the afternoon, the 7 year old sister developed blurred vision.

9th November: the 7 year old sister developed sore throat – admitted to Sterling Hospital and when deteriorating was taken to PICU in Glasgow and ventilated.

NO D&V - no fever – CT scan and MRI normal – LP normalNeurology and immunology team: botulism as the most likely diagnosis Children received antitoxin and stabilisedColindale alerted


Foodborne botulism – Scotland 2011

10th November: first teleconference

• Children received antitoxin and stabilised

• The parents and the 3 year old sibling have no symptoms.

• Food history: try to identify plausible foods eaten within 36h from onset of symptoms, by the children only.

Olives in jar (lots of discussion about olives because of recent botulism outbreak in Helsinki and France)


Foodborne botulism – Scotland 2011Olives in jar Carrots Pitta bread Humus Curry sauce in jar with chicken: dad said ‘ smell funny’ but gave it to the children Hot dogs Cheese Chicken nuggets Sun dried tomatoes in oil Rice Potatoes Peppers Vanilla yoghurt Salad Smoothies biscuits Cereal Banana milkshake Frozen raspberries honey



IN OUTOlives in jar Grilled chickenCurry Sauce in jar Homemade biscuitsYoghurt CarrotsHoney RaspberriesPitta Bread Pasta, chicken, tomato sauce Humus broccoliSundried tomatoes Cereal

Banana Milkshake


Foodborne botulism – Scotland 2011Food item Specimen information Toxin detection

by MBAC. botulinum

detection by PCRComments on PCR results

M&S wholemeal Pittas From rubbish bin Not detected C. botulinum A Spores only detected.

Remnant of Korma sauce +Chicken From wheelie bin Toxin A detected C. botulinum A Vegetative cells and

spores detected

Lid from the consumed korma sauce jar From rubbish wheelie bin Toxin A detected C. botulinum A Vegetative cells and

spores detected

Empty jar of consumed korma sauce From recycling bin Toxin A detected C. botulinum A Vegetative cells and

spores detected

Korma sauce jarOpened but not

consumed; From dry good cupboard

Not detected Negative

Empty container of olives From wheelie bin Not detected Negative

Oil from sun-dried tomatoes From fridge Not detected Negative

Houmous From fridge Not detected Negative

FSA issued National product recall


Patient specimen information

Date of collection Toxin detection by MBA C. botulinum

detection by PCR

Boy Serum 08.11.11 Not performed/ haemolysed NA

boy Blood 09.11.11 Not performed/ haemolysed NA

Boy Blood 09.11.11 Not performed/ EDTA treated NA

Girl Serum 09.11.11 Toxin detected - Classic symptoms of botulism observed, insufficient

serum for confirmatory neutralisation test

NA

Boy Serum 09.11.11 NA

Girl Blood 10.11.11 Not performed/ haemolysed NA

Girl Blood 10.11.11 Not performed/ EDTA treated NA

Girl Rectal washout in Anaerobic broth 10.11.11 Not performed C. botulinum A

Boy Rectal washout in Anaerobic broth 10.11.11 Not performed C. botulinum A

Boy Rectal washout 10.11.11 Not detected C. botulinum A

Boy Gastric aspirate 10.11.11 Not detected Negative

Girl Gastric aspirate 10.11.11 Not detected Negative

Girl Rectal washout 10.11.11 Not detected Negative



16th November:3rd sibling, a 3 year old girl, admitted to hospital after choking on food – gagged on food collapsed a few time and eyes were droopy.Taken to A&E with ptosis – then discharged the next day !

17th November:Choked on food again – antitoxin given

23rd November:Stool specimen for 3 year old PCR Positive for neurotoxin gene A


How to prevent foodborne botulismC. botulinum has to grow to produce toxin. The main limiting factors for growth of C. botulinum in foods are:

1. temperature, (optimum growth is 35°C or 25°C)

2. pH, below 4.6

3. water activity, (min aw of ~0.94 is needed for growth) 10% NaCl

4. redox potential, presence of oxygen

5. food preservatives, (nitrite, sorbic acid, polyphosphates..)

6. competing microorganisms, lactic acid bacteria, intestinal microflora.

7. ‘Botulinum cook’: pressure cooker 121°C for 3 minutes


Who to speak to???

Clinical diagnosis:• Consult neurologist and local ID Physician• Botulism duty doctor protocol (HPA website)

Microbiology confirmation and Guidelines and advice on specimens, availability and interpretation of results: • Reference laboratory Colindale• GBRU User Manual (LGP user manual HPA website)• Dr Corinne Amar or Dr Kathie Grant

Availability of antitoxin:• Duty doctor in Colindale• BabyBIG: Infant Botulism Treatment and Prevention

Programme, California, USA. http://www.infantbotulism.org/

http://www.infantbotulism.org/


Thank You,

Foodborne Botulism or… Please don’t pass the olives! Unusual cases of food poisoning. Corinne...

Documents

Transcript of Foodborne Botulism or… Please don’t pass the olives! Unusual cases of food poisoning. Corinne...