A DISTINCT KIND OF MORNING SICKNESS: WOUND BOTULISM IN A PREGNANT FEMALE

Abstract

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Wound botulism is caused by contamination with Clostridium Botulinum spores. When the spores germinate, they produce a potent neurotoxin causing the characteristic descending flaccid paralysis. Botulism in pregnancy may be amplified due to natural physiological changes. To the best of our knowledge, there have been only two other cases reported of pregnant women with wound botulism. CASE PRESENTATION: This is a 38-year-old female with hypertension, asthma, and 10-week intrauterine pregnancy who presented with two weeks of diplopia, dysphasia, dysarthria, anorexia, and ptosis followed by symmetric and progressive weakness in her legs. Physical exam revealed diminished patellar reflexes, weakness of bilateral lower extremities, and swollen and bruised forearms, without ultrasound evidence of fluid collection. Due to decreased vital capacity, she was intubated for airway protection. Initial serological and spinal fluid studies were normal. Brain and spine imaging were unremarkable. Electromyography (EMG) revealed gross reduction in motor response amplitudes suggestive of an axon loss variant of Guillan Barre syndrome. IVIG therapy was initiated. Due to progressive weakness and persistent ventilator support, the patient underwent tracheostomy. Further history provided by significant other confirmed IV drug use 2 weeks prior broadening the differential diagnosis. Acetylcholine receptor binding antibody was negative, yet botulism neurotoxin was positive and the heptavalent antitoxin was administered. Repeat EMG demonstrated progressive low amplitude compound muscle action potentials with minimal increment and early recruitment on rapid repetitive stimulation suggested the presence of a presynaptic neuromuscular junction defect consistent with botulism. The patient’s clinical status dramatically improved. Although her fetus was unharmed, she decided to terminate her pregnancy due to psychosocial issues. DISCUSSION: Unlike foodborne botulism, wound contamination requires spore germination before the toxin can be released resulting in longer incubation periods. The neurotoxin inhibits the release of acetylcholine from the motor neurons to the muscles. The blockade is most pronounced in the cranial nerves and muscles of respiration, sparing sensory innervation. Treatment must be initiated with a presumptive clinical diagnosis, as laboratory confirmation is timely. Prognosis is favorable with proper respiratory support and early recognition. There is minimal literature describing maternal and fetal outcomes, however congenital botulism or neonatal loss is deemed unlikely. CONCLUSIONS: Early recognition and neutralization of the neurotoxin is paramount to improve outcomes. Pregnant women physiologically have increased oxygen consumption causing rapid progression of respiratory failure. There are no known adverse maternal or fetal outcomes from treatment or infection of botulinum toxin. Reference #1: Burningham, Mark D, et al. “Wound Botulism.” Anals of Emergency Medicine 1994 Dec;24(6):1184-1187. Reference #2: Thwaites, C.L. "Botulism and tetanus.” Medicine 2017 Dec;45(12):739-742. Reference #3: Rimawi, Bassam H. "Botulism During Pregnancy and the Postpartum Period: A Systematic Review.” Clinical Infectious Disease 2018 Jan;66(Suppl 1):S30-S37. DISCLOSURES: No relevant relationships by Aarti Mittal, source=Web Response No relevant relationships by Erin Wiltchik, source=Web Response