An outbreak of botulism in Thailand: clinical manifestations and management of severe respiratory failure.
BACKGROUND
Northern Thailand's biggest botulism outbreak to date occurred on 14 March 2006 and affected 209 people. Of these, 42 developed respiratory failure, and 25 of those who developed respiratory failure were referred to 9 high facility hospitals for treatment of severe respiratory failure and autonomic nervous system involvement. Among these patients, we aimed to assess the relationship between the rate of ventilator dependence and the occurrence of treatment by day 4 versus day 6 after exposure to bamboo shoots (the source of the botulism outbreak), as well as the relationship between ventilator dependence and negative inspiratory pressure.


METHODS
We reviewed the circumstances and timing of symptoms following exposure. Mobile teams treated patients with botulinum antitoxin on day 4 or day 6 after exposure in Nan Hospital (Nan, Thailand). Eighteen patients (in 7 high facility hospitals) with severe respiratory failure received a low- and high-rate repetitive nerve stimulation test, and negative inspiratory pressure was measured.


RESULTS
Within 1-65 h after exposure, 18 of the patients with severe respiratory failure had become ill. The typical clinical sequence was abdominal pain, nausea and/or vomiting, diarrhea, dysphagia and/or dysarthria, ptosis, diplopia, generalized weakness, urinary retention, and respiratory failure. Most patients exhibited fluctuating pulse and blood pressure. Repetitive nerve stimulation test showed no response in the most severe stage. In the moderately severe stage, there was a low-amplitude compound muscle action potential with a low-rate incremented/high-rate decremented response. In the early recovery phase, there was a low-amplitude compound muscle action potential with low- and high-rate incremented response. In the ventilator-weaning stage, there was a normal-amplitude compound muscle action potential. Negative inspiratory pressure variation among 14 patients undergoing weaning from mechanical ventilation was observed. Kaplan-Meier survival analysis identified a shorter period of ventilator dependency among patients receiving botulinum antitoxin on day 4 (P=.02).


CONCLUSIONS
Patients receiving botulinum antitoxin on day 4 had decreased ventilator dependency. In addition, for patients with foodborne botulism, an effective referral system and team of specialists are needed.
Kongsaengdao
Subsai
S
Department of Medicine, Rajavithi Hospital, Ratchathewi, Bangkok, 10400, Thailand. skhongsa@gmail.com
Samintarapanya
Kanoksri
K
Rusmeechan
Siwarit
S
Wongsa
Adisorn
A
Pothirat
Chaicharn
C
Permpikul
Chairat
C
Pongpakdee
Sunsanee
S
Puavilai
Wilai
W
Kateruttanakul
Piraj
P
Phengtham
Uthai
U
Panjapornpon
Kanlaya
K
Janma
Jirayut
J
Piyavechviratana
Kunchit
K
Sithinamsuwan
Pasiri
P
Deesomchok
Athavudh
A
Tongyoo
Surat
S
Vilaichone
Warakarn
W
Boonyapisit
Kanokwan
K
Mayotarn
Saengduan
S
Piya-Isragul
Benjamas
B
Rattanaphon
Aran
A
Intalapaporn
Poj
P
Dusitanond
Petcharat
P
Harnsomburana
Piyathida
P
Laowittawas
Worapojn
W
Chairangsaris
Parnsiri
P
Suwantamee
Jithanorm
J
Wongmek
Wanna
W
Ratanarat
Ranistha
R
Poompichate
Akekarinth
A
Panyadilok
Hathai
H
Sutcharitchan
Niwatchai
N
Chuesuwan
Apinya
A
Oranrigsupau
Petchdee
P
Sutthapas
Chumpita
C
Tanprawate
Surat
S
Lorsuwansiri
Jakapong
J
Phattana
Naritchaya
N
D001906:Botulism / Q000453:epidemiology* / Q000503:physiopathology; D003014:Clostridium botulinum; D004196:Disease Outbreaks; D006801:Humans; D012131:Respiratory Insufficiency / Q000209:etiology; D013785:Thailand / Q000453:epidemiology; D014691:Ventilation