Intestinal Abscess Caused by Botulism

Abstract

Introduction: Botulism is a rare but life threatening neuroparalytic condition caused by bacterium Clostridium botulinum. We report a case of a middle-aged male who developed intestinal abscesses that were secondary to Botulism. Case: A 43-year-old male was admitted to our institution with abdominal pain, blurred vision and dysarthria for one day duration. He denied any fever, headache or neck stiffness. Past medical history was significant for diabetes mellitus, hypertension and gout. Examination revealed normal vital signs, inability to protrude the tongue with no evidence of palpable adenopathy or rash. MRI brain was unremarkable. Laboratory values showed leukocytosis of 20.3 K/microliter and platelet count of 602 K/microliter. CT scan abdomen and pelvis showed multiloculated gas containing fluid collections in the perigastric area and in left anterior abdominal wall. Abscesses were incised and drained and culture from the abscess was positive for Clostridium botulinum type A toxin. Serum, stool and gastric aspirate were assayed using mouse bioassay which were positive for type A botulinum toxin. Subsequently, patient developed respiratory failure and was intubated requiring mechanical ventilatory support. The patient got botulinum antitoxin and was treated with imipenem. Subsequently, his condition started improving and is recovering neurologically in the last three weeks of follow-up. Discussion: Botulism is an acute neuroparalytic condition characterized by cranial nerve palsies followed by descending symmetrical flaccid paralysis which can cause respiratory arrest and can be fatal. Botulism is caused by botulinum neurotoxin types A, B, E or F and G produced by Clostridium species (C. botulism, C. baratti, C. butyricum). Three major forms of botulism are: 1) Food borne botulism from ingestion of food contaminated by preformed botulism neurotoxin. 2) Intestinal botulism caused by colonization from Clostridium botulinum followed by in situ production of toxin. 3) Wound botulism caused by contamination of wound by Clostridium botulinum and production of neurotoxin in situ. A careful history and physical examination, serum assays, analysis of stool and suspected food item may also reveal neurotoxin which is diagnostic when coupled with appropriate clinical and neurological findings. If clinical suspicion for botulism is high, Centers for Disease Control and Prevention (CDC) should be contacted for administration of botulism antitoxin which is the standard of care followed by antibiotics. To summarize, our case reiterates the importance of early and prompt diagnosis of botulism which is a fatal disease to initiate therapy in a timely fashion.