Clostridium Botulinum: Friend or Foe?

Botulism is a serious neurological illness with potentially life-threatening neuroparalysis caused by a nerve toxin produced by the bacterium, Clostridium botulinum (Shapiro, Hathaway, & Swerdlow, 1998) The neurotoxin acts prefentially on presynaptic membranes of peripheral neuromuscular nerve junctions and blocks acetylcholine release, resulting to flaccid muscle paralysis (Glogau, 2003).

C. botulinum is considered as a friend for its many clinical applications as well as a foe for this also causes the well-known fatal and crucial disease botulism. Its potential to be used as a bioterrorist agent is as well taken into account. (Arnon, Inglesby, Henderson, Bartlett, & Ascher, 2001).

Botulinum toxin type A, is one of the most pathogenic substance to humans. It is a neurotoxin protein produced by C. botulinum that causes the potentially fatal food borne botulism, infant botulism and wound botulism (Glogau, 2003). Administered in minute doses, it can be an agent to treat conditions such as dystonia and tension headache (Jankovic, 1990; Mauskop, 2002) . It is also used cosmetically to temporarily smooth facial lines and iron wrinkles because of its muscle-relaxing effects (Aoki, 1998).  Its therapeutic advantages are very promising.

Additionally, because of the potency of the toxin, the intentional release of C. botulinum toxin to cause an outbreak is not a remote possibility. The possibility of botulism as a product of malice, as a bioterrorism agent or biological weapon by rogue states and terrorist groups is a great concern (Henderson, 1999).

Introduction

Clostridium botulinum, is an anaerobic, Gram-positive, spore-forming bacilli, which was first isolated and identified by Emile-Pierre van Ermengem, a Belgian microbiologist in 1895 (AHW, 1989).

C botulinum is widely distributed throughout the environment. These rod-shaped spore-forming bacteria grow suitably in low-oxygen conditions. The spores of C. botulinum are commonly found in both forest and cultivated soils, in sediments of streams, lakes, and oceans. The spores can also be found in low numbers in the normal intestinal flora of mammals, birds and fish, as well as in the gills of some shellfish. C botulinum spores are heat-resistant and allow the bacteria to continue to exist in a dormant state until they are exposed to an excellent condition suitable for growth (Oguma, Fujinaga, & Inoue, 1995).

Clostridium botulinum produces the botulinum toxin, which is known to be one of the most dangerous toxins in existence (Wells & Wilkins, 1996). As the most poisonous of all known poisons (Shukla & Sharma, 2005), the pathogenesis of the agent infecting humans was investigated. Botulinum neurotoxin is a complex, polypeptide protein with characteristic neurotoxicity, which is responsible for botulism, a serious and often fatal neuroparalytic illness in humans and animals which was recognized in 1793 (Oguma, Fujinaga, & Inoue, 1995).

Clostridium botulinum was identified as the cause of botulism. On the basis of antigenic specificity of its toxin, it has been divided into 7 types: A, B, C, D, E, F, and G. In addition to Clostridium botulinum, some other species of Clostridium like C. butyricum and C. baratii also produce the toxin (Bali and Thakur, 2005)

The serotypes are antigenically unique, but do have specific regions of amino acid structure. The toxins are about 150 kilo Daltons in molecular weight. The active molecule is double chain, consisting of a light and a heavy chain. It has three functional domains: a binding domain at the C terminus of the heavy chain, a translocation domain at the N terminus of the heavy chain, and a catalytic domain at the C terminus of the light chain, which is a zinc metalloprotease (Cunningham, Teller, Quinn, & Ryan, 2004).

A crude form of botulinum toxin A was produced by Dr. Herman Sommer in 1926. Dr. Edward Schantz on the other hand, first produced purified toxin A in 1946. In the late nineteen seventies, botulinum toxin was used by Dr. Alan Scott through injection into the extraocular muscles for correction of strabismus (Bali and Thakur, 2005).

There are three main kinds of botulism:

• Foodborne botulism occurs when a person takes in pre-formed toxin through ingestion that leads to illness within a few hours to days. Foodborne botulism is of a public health importance because it is considered as an emergency case due to the contaminated food that may also be taken in by the other persons besides the patient.
• Infant botulism occurs rarely. However, susceptible infants who harbor C. botulinum, has the organism in their intestinal tract.
• Wound botulism occurs when wounds get contaminated with C. botulinum that produces the toxin (Prevention, 2001).

In ruminants, botulism primarily occurs in areas where phosphorus or protein deficiencies are found. Botulism is seen commonly in cattle in South Africa and sheep in Australia. This disease is rare in ruminants in the United States, although a few cases have been reported in Texas and Montana (“Botulism”, 2003).

Botulism in animals has different names. Some of which are the following; Shaker Foal Syndrome, Limberneck, Wester, Duck Sickness,Bulbar Paralysis,Loin Disease, Lamziekte (“Botulism”, 2003).

Preformed toxins in an array of sources, involving decaying vegetable matter (grass, hay, grain, and spoiled silage) and carcasses can cause botulism in animals. Carnivores, including mink and commercially raised foxes, commonly take in the toxins in infected meat such as chopped raw meat or fish. Cattle in phosphorus-deficient areas may chew bones and residues of attached meat; a gram of dried flesh may have optimum amounts of botulinum toxin to kill a cow.

Similar instances happen in Australia, wherein protein-deficient sheep at times eat the carcasses of rabbits and other small animals. Ruminants may also be given hay or silage contaminated by carcasses of birds or mammals contaminated by the toxin. Horses usually ingest the toxin in contaminated ration. Birds can get the toxins in maggots that have fed on carcasses contaminated by the toxin or in dead invertebrates from water with decaying vegetation. Cannibalism and contaminated feeds can also cause botulism cases in poultry (“Botulism”, 2003).

Botulinum toxin is the causal agent of the fatal form of neuroparalytic botulism, it has been also used in treating a variety of involuntary muscle contractions or disorders such as strabismus and blepharospasm (Relja, 2000). Paralysis is also caused by neurotoxins acting at the neuromuscular junction blocking the presynaptic release of acetylcholine (Shukla & Sharma, 2005). Moreover, botulinum toxin is also used in cosmetology in smoothing facial lines in facial spasms (Blitzer, Binder, & Brin, 2000). And believe it or not, the active component of Botox, a popular anti-aging medication, is the botulinum toxin (Aoki, 1998).

The different reactions of botulinum toxin (BTX) in relative to food poisoning were known since the Roman times. In the Middle Ages studies were already conducted to prevent outbreaks of botulism through better hygienic regulations. By the time of the last century the connection between botulism, the responsible bacteria and the existence of BTX was explained. Via animal trials and molecular biological investigations, the specific studies  and effects of BTX were then discovered (“Understanding the use of botulinum toxin in the treatment for dystonia”, 2005).

Botulinum Toxins

Generally, most bacterial species have strains with close genetic relationship and comparable characteristics in cultures.  The genus Clostridia consists of more than one hundred and twenty-seven distinct groups of species. These species are endospore-forming, gram-positive bacilli and are commonly found in soil. These are also rod-shapped organisms that grow best in low-oxygen environments and form spores that allow them to last in a latent state until exposed to conditions that can aid their growth (Wells & Wilkins, 1996).

The species C. botulinum can be distinguished on the basis of physiological, biochemical and cultural uniqueness (Shukla & Sharma, 2005). Unlike most species of bacteria, which have strains that have a related genetic make-up and similar cultural feature, the C botulinum “species” consists of certain unique groups of microorganisms that have a common name only because they yield similar toxins. Hence, name C botulinum is only an advancement that reflects the medical value of the species (Wells & Wilkins, 1996).

Furthermore C. botulinum produces seven serotypes of neurotoxins. Each toxin produced by each strain is antigenically distinct with its own unique characteristics. The seven serotypes of botulinum toxin are labeled with the letters A, B, C1, D, E, F and G. No botulinum toxins are alike; each has its own characteristic properties and specific actions (Glogau, 2003).

Of the seven different serotypes of botulinum neurotoxin, humans are most susceptible to types A, B, E and F.  On the other hand, the types C and D are pathogenic to animals. As such, they are poisonous and can cause botulism in some animals such as wild fowl and poultry, fish, horses and cattle. No outbreaks involving type G have been recognized yet (Erbguth, 1999). For infections that are type G caused are of rare case in humans (Wells & Wilkins, 1996).

For types A and B producing strains, the optimal temperature for its survival is 35-40°C.  To destroy these types, it requires 25 minutes at 100°C. On the other hand, the most favorable temperature for type E is 18-25°C for growth.  Destruction of this strain takes only about 0.1 minute at 100°C to destroy it (Chia, Clark, Ryan, & Pollack, 1986). C botulinum spores are found widely in the soil (including in sea sediments) and in low amounts in the gastrointestinal tracts of some birds, fish, and mammals. The spores are heat enduring and can tolerate 100° C for hours, but the toxin is comparably heat labile (Wells & Wilkins, 1996).

There are four steps or stages in the cellular action of this neurotoxin. In the first step, the toxin attaches to the presynaptic membrane of the target neuron. The heavy chain of the toxin protein permits binding through high-affinity cell surface receptors that are specific for each type of botulinum toxin (Mauskop, 2002; Simpson, 2004).

In the second step of the process, the toxin penetrates the presynaptic plasma membrane of the poisoned cell. The cell then engulfs the neurotoxin through receptor-mediated endocytosis into the nerve terminal (Marvaud, Raffestin, & Popoff, 2002; Simpson, 2004).

The third step involves the formation of an endosome or vesicle containing the toxin. When the endosome becomes acidic, a pH of about 5.5 or lower, the toxin molecule changes and the light chain of botulinum toxin cleaves specific sites on the SNARE proteins, preventing complete assembly of the synaptic fusion complex and thereby blocking acetylcholine release (Giladi, 1997; Simpson, 2004).

Without acetylcholine, the muscle is not able to contract. SNARE is indicative of soluble NSF-attachment protein receptor; NSF, N-ethylmaleimide-sensitive fusion protein; and SNAP-25, synaptosomal-associated protein of 25 kd. It is in the light chain that the entire toxic activity of botulinum takes place. Once the light chains with the botulinum of the nerve terminal, they act as a zinc-dependent endoprotease that selectively cleaves specific protein polypeptides bonds crucial for exocytosis. This step thus concludes the whole mechanism of action of botulinum toxin (Simpson, 2004; Stephen S. Arnon, 2001).

Each of the seven botulinum toxins serotypes attacks and cleaves a specific different protein bond. Synaptobrevin, which is also referred to as vesicle-associated membrane protein (VAMP), is a synaptosomal membrane protein. Tetanus neurotoxin, botulinum toxin types B, D, F, and G cause the removal of most of the VAMP at the cytoplasmic surface of the synaptic endosome as a result of their cleavage activities. Botulinum toxins A and E act on synaptosomal-associated protein of 25 kDa (SNAP-25), while serotype C1 mainly cleaves syntaxin and SNAP-25. These series of proteins (VAMP, syntaxin and SNAP-25) are necessary for acetylcholine release (Giladi, 1997; Simpson, 2004).

Each of these cleavages impedes the docking of the vesicle membrane thereby preventing exocytosis and release of the vesicle-bound acetylcholine. Blocking the presynaptic release of the neurotransmitter acetylcholine from the nerve endings is related to the classic characteristics of botulism which are flaccid muscle paralysis and autonomic dysfunction. (Oguma, Fujinaga, & Inoue, 1995; Simpson, 2004).

It is possible to have botulism without the multiple cranial nerve palsies. Clinical signs are similar regardless of the toxin type. However, the extent and length of paralysis may vary among patients. Some patients may be mildly affected (Figure 3), while others may be so paralyzed that they appear comatose and require months of breathing support. The speed of onset and the severity of paralysis are dependent on the amount of toxin absorbed into the system. Healing results from new motor axon twigs that sprout to reinnervate paralyzed muscle fibers, a process that, in adults, may take weeks or months to complete.

A, Patient at rest. Note bilateral mild ptosis, dilated pupils, disconjugate gaze, and symmetric facial muscles. B, Patient was requested to perform his maximum smile. Note absent periorbital smile creases, ptosis, disconjugate gaze, dilated pupils, and minimally asymmetric smile. As an indication of the extreme potency of botulinum toxin, the patient had 40 x 10-12g/mL of type A botulinum toxin in his serum (ie, 1.25 mouse units/mL) when these photographs were taken (Stephen S. Arnon, 2001).

When the botulinum toxins attach themselves to the nerve endings, the neurotransmitter acetylcholine cannot be released, Acetylcholine plays a vital role in sending electrochemical messages from the nerves to the muscles to trigger them contract and move.  The motor synapse is the area where the nerve meets the muscle. When excessive acetylcholine neurotransmitter is released, it results in overactive muscles (as seen in tetanus paralysis, exemplified by its familiar name, “lockjaw” fever) However, when the synaptic acetylcholine release is blocked, the muscle attached to the nerve becomes flaccid, paralyzed and atrophied, as in botulism intoxication (Simpson, 2004).

Botulinum Toxin Type A

Botulinum toxin A is one of the neurotoxins derived from the bacterium C. botulinum. It is the most potent and most lethal poison known to man. In fact intake of about 10-8 grams of this toxin can cause death in humans (Glogau, 2003; Oguma, Fujinaga, & Inoue, 1995).

Many years of research has led to the discovery that botulinum toxin type A, although potentially lethal (causing food-related paralysis called botulism), can be tapped for treating several medical conditions caused by overactive muscles because of its muscle-relaxing properties (Jankovic, 1990). The therapeutic toxin is a neurotoxin-hemagglutinin complex obtained by growing cultures of C. botulinum in a fermenter, which were later harvested and the toxin purified from the cultures. (Silberstein, Mathew, Saper, & Jenkins, 2002).

Clostridium botulinum and Botulism

Botulism is a symmetrical, descending paralytic disease caused by the neurotoxin produced by C. botulinum (Chia, Clark, Ryan, & Pollack, 1986). This disease has different modes of action or point of entries other than the oral route; it can also be a result of toxin inhalation or wound contamination. There are three forms of botulism classified on how they are contracted: food, wound and infant botulism  (AHW, 1989).

The symptoms of botulism can be manifested in the nervous system as well as in the alimentary tract of the infected individual. The clinical effects become evident 24-74 hours after exposure to the neurotoxin (Shapiro, Hathaway, & Swerdlow, 1998). The primary and most serious effect of the toxicity mechanism of botulism is muscle paralysis, because the botulinum toxins block the presynaptic release of the neurotransmitter that would signal the muscles to contract.

Botulism patients are fully alert and will show normal results of sensory examinations. But they may exhibit a multitude of clinical symptoms such as blurred vision, difficulty swallowing, drooping eyelids, double vision, drooping eyelids, dry mouth, and slurred speech. The clinical signs of the illness are cranial nerve palsies, pupillar alterations, digestive disorders, and bilateral descending peripheral muscular weakness (first the shoulders, then the upper arm, down to the feet). If left untreated, it may progress to paralysis (Chia, Clark, Ryan, & Pollack, 1986).

If these symptoms are left unchecked and the toxic mechanism is not immediately terminated, muscle paralysis may extend to the thoracic and respiratory muscles, which could have a profound impact on breathing. Respiratory paralysis is one of the most feared sequellae. Deaths from botulism are often due to respiratory muscle paralysis, which makes breathing impossible (Arnon, Inglesby, Henderson, Bartlett, & Ascher, 2001).

The neurotoxin type and the amount of the toxin contracted serve as basis in determining the severity of the illness (Shapiro, Hathaway, & Swerdlow, 1998). The timely intravenous administration of the specific equine antitoxin to the toxin type is crucial in arresting the descending progression of bilateral muscle paralysis and in shortening the duration of the illness. This is the best way to prevent respiratory system involvement. Antitoxin works only on neurotoxins circulating freely in the blood, because once they are already in the neurons, it cannot be attacked by the antitoxin anymore (Chia, Clark, Ryan, & Pollack, 1986).

Mainstays of therapy management includes close monitoring, intensive care unit support and mechanical ventilator while nerve sprouting and new terminal formation takes place (Shapiro, Hathaway, & Swerdlow, 1998). Fading of the clinical effects of botulism is accompanied by the sprouting of new nerve terminals. The formation of the new neuromuscular junctions adjacent to these sprouts provides new avenues of communication with the muscle (Chia, Clark, Ryan, & Pollack, 1986). Full recovery from the disease takes about several weeks to months. Prognosis is generally good with early and prompt detection, early administration of antitoxin and thorough supportive therapy (Glogau, 2003).

Food Botulism

Foodborne botulism is a severe form of food poisoning caused by the ingestion of the preformed neurotoxin produced by the vegetative cells of C. botulinum in improperly preserved food. The incubation time is usually 18-36 hours after ingestion.  The toxin that is absorbed in the intestinal mucosa is only a small, yet effective percentage of the ingested toxin. The rest of the ingested toxin is passed out in the feces. Case-patients of food botulism when tested are  positive for botulinum toxin in serum, stool and gastric secretions tests(Chia, Clark, Ryan, & Pollack, 1986; Sobel, Tucker, Sulka, McLaughlin, & Maslanka).

Intoxication can be via ingestion of food that is already contaminated with botulinum toxin especially if food already tainted with C. botulinum is prepared or stored in a way conducive to growth and multiplication of the organisms. This makes the contaminated food a culture medium for the bacteria. As the organism mature, they release the toxin. In other cases, patient may ingests food that has C. botulinum spores that may develop and inhabit the gut.  As the spores develop into vegetative cells, these release the toxin (Chia, Clark, Ryan, & Pollack, 1986; Sobel, Tucker, Sulka, McLaughlin, & Maslanka).

It was in 1817 when Justinus Kerner described the clinical picture of poisoning with botulinum toxin in contaminated sausage (sausage is botulus in Latin).

He confirmed that death from botulinum toxin poisoning is a result of muscle paralysis (Erbguth, 1999). Although rare, foodborne botulism is a serious disease. Even though botulism occurs rarely; it incites major concern because of its high fatality rate if not treated promptly and appropriately (Sobel, Tucker, Sulka, McLaughlin, & Maslanka).

From 1990-2000, 214 cases of foodborne botulism cases were recorded in nine states with five or more cases (Table 1), with Alaska ranking first in terms of high incidence rate. An outbreak was characterized as two or more cases of botulism caused by consuming contaminated food (Sobel, Tucker, Sulka, McLaughlin, & Maslanka). Incidence of an outbreak in the table includes all the states because an outbreak means any group of individuals that are infected with a common disease.

Early gastrointestinal symptoms of food botulism occurring after 12-36 hours are nausea, vomiting, diarrhea or constipation, and abdominal pain. Case-patients also experience muscular weakness and paralysis and sometimes have the critical involvement of paralysis of the respiratory tree (Erbguth, 1999).

Improperly processed home-canned foods are associated with most of the outbreaks of food botulism reported annually in the United States. Sausages, canned vegetables, seafood products and meat products are the major sources for human botulism. As such, germs easily multiply in vacuum-packed foods (Sobel, Tucker, Sulka, McLaughlin, & Maslanka). Management and handling faults definitely are also factors for the occurrence of the foodborne botulism, as well.

The spores of C. botulinum can be airborne, so it is also possible for it to find their way into food being packed in cans and jars. If heating is not sufficient to kill endospores, pH alteration could also be done since the spores survive highly in acidic environments, making the condition alkaline, could inactivate the spores from germination. Once the cans and jars are sealed, the anaerobic condition allows C. botulinum spores to thrive and germinate; the germs multiply and release their potent toxin. Other conditions that support bacterial growth and toxin release, besides a low-oxygen environment are low-salt and low-acid environments (Chia, Clark, Ryan, & Pollack, 1986).

Barriers to C. botulinum germination in vacuum-packed foods include refrigeration, acidification and reduced water activity.  Bacterial growth and multiplication can be prevented in temperatures below 4°C. Meat or vegetables that will be bottled and or canned should be thoroughly heated. C. botulinum growth is inhibited in temperatures over 100oC  as well as the vegetative cells, heating the second time around can inactivate any germinated spores that had survived the first round of heating. Botulinum toxin itself can be inactivated and destroyed if heated at 85°C for 10 minutes or longer (Glogau, 2003; Shapiro, Hathaway, & Swerdlow, 1998).

Botulism patients should be closely observed and require intensive care. In persons suspected of ingesting contaminated food, stomach lavage can be used. Cathartics and high enemas to eliminate residual and unabsorbed toxins can be used with great caution in patients with bowel paralysis. The best intervention to those with overt symptoms and to those who have positively ingested tainted food is immediate administration with an anti-toxin (Trivalent ABE) to lessen the risk of morbidity and mortality (Chia, Clark, Ryan, & Pollack, 1986; Sobel, Tucker, Sulka, McLaughlin, & Maslanka).

Known and suspected cases of foodborne botulism should be reported immediately to authorities to be reported back to the Centers for Disease Control and Prevention (CDC) so that appropriate steps can be taken to minimize the risk of an outbreak. The only source of therapeutic antitoxin is the CDC which maintains a 24-hour antitoxin (Trivalent ABE) release service around the country (Shapiro, Hathaway, & Swerdlow, 1998). Every case of food borne botulism is considered as a public health emergency because of the possibility of large numbers of people being affected because of contamination of a widely distributed food product (Arnon, Inglesby, Henderson, Bartlett, & Ascher, 2001).

Infant Botulism

Infant botulism is distinctly a different form of botulism. In infant botulism, C. botulinum populate is consumed in its spore form, spores germinate, and vegetative cells synthesize and release the botulinum neurotoxins in the gastrointestinal tract of the infant. C. botulinum colonizes in the gut of infants younger than one year of age because they relatively lack gastric enzymes, have low levels of normal intestinal flora, and have underdeveloped immune systems.

The duration of the whole process of bacterial proliferation and toxin production last a few days. It may occur in children less than one year of age, but most cases reported occurred in infants between 2 weeks and 6 months of age. The ingestion of honey is the most common source of the C.botulinum spores and has been identified as a risk factor for infant botulism (Arnon, 1980; Davis, 1993; Elad, 2006).

Food-borne and infant botulism produce symptoms that affect the nervous system. The infant with botulism is normally without fever. A prominent early sign of infant botulism is constipation. Other clinical features that the infant manifests are generalized muscle weakness; lethargy, cries weakly, drools as oral secretions pool, sucks poorly, sleeps more and has poor muscle tone. Later on, the toxin eventually leads to head lag and poor head control giving the infant the flaccid floppy appearance (Arnon, 1980; Risko, 2006). If left unchecked, most cases progress to the respiratory arrest and ultimately death (Shapiro, Hathaway, & Swerdlow, 1998).

Supportive care is central in the treatment and therapy of infant botulism. Infants should be closely monitored with respiratory equipment readily available. Antibiotic use is contraindicated for infant botulism because cell death may result in the release of more toxins. The clinical symptoms usually subside with supportive therapy and even without the use of an antitoxin; the infant mortality rate is less than 1% (Arnon, 1980).

Wound Botulism

Comparatively, wound botulism, is a rare disease that results from C. botulinum that thrives in necrotic tissues of a wound. The toxin is produced by the organism inhabiting the wounds and the toxin spreads systemically. Wound botulism is usually associated with subcutaneous black tar heroin injection, surgery or trauma (Shapiro, Hathaway, & Swerdlow, 1998).

Symptoms develop after an incubation period of a few days to a couple of weeks. The clinical symptoms of wound botulism are similar to foodborne botulism but have no gastrointestinal involvement. (Oguma, Fujinaga, & Inoue, 1995).

The important aspects of therapy, once wound botulism is diagnosed are:

• elimination of the source of toxin,
• getting rid of the unabsorbed toxins,
• neutralization of any unbound toxin with specific antitoxin
• provision of supportive care (Vangelova, 1995).

The primary modes of treatment in wound botulism are debridement and antibiotic therapy with penicillin G or metronidazole to control the offending bacterium. Equine antitoxin (Trivalent ABE) therapy is only effective in wound botulism if it is administered early.  This substance is readily available from CDC through the different statewide health departments (Arnon, Inglesby, Henderson, Bartlett, & Ascher, 2001).

Coupled with this intervention is close and careful monitoring of the case-patient and accessibility of respiratory support facilities because respiratory failure may come about within few minutes (Shapiro, Hathaway, & Swerdlow, 1998).

In wound botulism, antitoxin therapy is most effective if administered early; however, clear-cut evidence for the efficacy of antitoxin therapy is available only in type E toxin. Unfortunately, all antitoxins are equine preparations, so a significant portion of patients experience reactions similar to anaphylaxis and serum sickness. Thus, before they receive antitoxin, all patients should be examined for sensitivity to horse serum (Bhidayasiri, Choi, & Nishimura, 2004; Wells & Wilkins, 1996).

The following advice may reduce the risk of wound botulism;

• Smoke heroin instead of injecting.
• If you must inject, do not inject into muscle or under the skin: make sure you hit the vein – your blood is better at killing bacteria than your muscle.
• Don’t share needles, syringes, cookers/spoons or other ‘works’ with other drug users.
• Use as little citric acid as possible to dissolve the heroin. A lot of citric acid can damage the muscle or the body under the skin, and this damage gives bacteria a better chance to grow.
• If you inject more than one type of drug, inject each at a separate place on your body and with clean works for each injection. This is important because certain drugs (e.g. cocaine) could give bacteria in heroin a better chance to grow.
• If you get swelling, redness, or pain where you have injected yourself, or pus collects under the skin, you should get a doctor to check it out immediately, especially if the infection seems different to others you may have had in the past (“Wound botulism cases in injecting drug users”, 2002)

A case of wound botulism reported was diagnosed on 2000. Upon further examination, the patient was known to have a long history of heroin injection. Botulinum toxin type A was positively detected in serum and samples producing botulinum toxin A were isolated from pus collected from a sinus in connection to an earlier abscess formation (“Wound botulism cases in injecting drug users”, 2002).

Botulinum Toxin as Bioweapon

Biological warfare has a long history; biological weapons have been used for waging war dating back to at least 1346. War isn’t just the use of explosives and firearms, but also the use of biological agents.

The use of biological agents for advocating war by several nations and terrorist groups is entirely feasible. It would enable them to inflict harm on target enemy combatants and civilians as well. Henderson (1999) noted that biological agents are in fact the most feared form of weapon of mass destruction over nuclear and chemical. In the ‘60s it was different, nuclear bombs being the most feared of all.

 (Arnon, Inglesby, Henderson, Bartlett, & Ascher, 2001) echoed that “biological agents have particular appeal for use in terrorist attacks because they are reasonably easy to acquire, are inexpensive to produce, and have the potential to affect large populations of people.”  The use of biological agents would not only indisputably result in a catastrophic impact on public health but would also cause widespread fear, havoc, anxiety and panic among the general population (Henderson, 1999).

Botulinum toxin remains the most potent of all toxins in existence (Glogau, 2003). Botulism toxin, anthrax, plague, tularemia, and smallpox are the most common biological agents that have been used as armors during that time. Because of its high lethality, high toxicity, ease of production and wide availability and the likely need for long-term intensive medical care treatment of its victims, botulinum toxin was classified by CDC as a high-risk potential agent of bioterrorism (Arnon, Inglesby, Henderson, Bartlett, & Ascher, 2001).

Investigations carried out by various nations revealed the use of C. botulinum neurotoxin as a biological weapon during World War II by the Japanese on their prisoners in Manchuria and the British in the killing of a German Gestapo officer. Alarmingly, after the 1991 Gulf War, Iraq disclosed stockpiling neurotoxins for use in their warheads. In early 1990s, Aum Shinriykö, a Japanese cult tried to use Clostridium toxin against US military targets; they attempted to distribute it as aerosols but unfortunately failed because of wrong microbiological method, deficient aerosol-generating tool, or internal sabotage. The terrorists got their C botulinum from soil that they had obtained in northern Japan (Cassiday, 2007; Henderson, 1999).

Among seven serotypes, C. botulinum type A was the one being used to act as biological agent. A drop of this toxin could kill thousands of unwitting victims. Furthermore, a dose of less than 1 microgram could already kill a human, that is why it is known to be one of the most poisonous substance today (Arnon, Inglesby, Henderson, Bartlett, & Ascher, 2001). As such, it poses a great threat because bioterrorists or enemy states might use it as an agent of biological warfare.

In the event of a bioterrorism attack, the most likely mode of attack is via intentional and deliberate contamination of food or water supply or by aerosolization to ensure that the toxin reaches members of the population to cause the botulism disease in them. Botulinum toxin must be highly refined to work as an aerosol for poison delivery in a bioterrorist attack due to its limitations in concentrating and stabilizing the toxin. Since the botulism disease is not contagious, only those who will fall ill will get the toxin via ingestion or inhalation (Arnon, Inglesby, Henderson, Bartlett, & Ascher, 2001).

Vaccine against C. botulinum toxin is currently available, however only professionals are allowed by the US Food and Drug Administration (FDA) to the use of the botulinum vaccine. Persons classified in special risk categories include laboratory researchers and workers who directly handle authorized botulinum toxin specimens. The supply of stocks is inadequate and that it’s not effective against all other forms and serotypes of the botulinum toxin (Henderson, 1999; Patocka, Splino, & Merka, 2005).

Other examples of biowarfare agents being used nowadays are Bacillus anthracis for anthrax, the pox virus for small pox, and Yersinia pestis for plague (Weber, 2004).

Medical Applications

In 1989, botulinum toxin type A was approved by the U.S. Food and Drug Administration for the treatment of a number of conditions such as strabismus (misalignment of the eyes), blepharospasm (forceful involuntary closure of the eyelids) and hemifacial spasm (sudden contraction of the muscles on one side of the face) (Blitzer, Binder, & Brin, 2000). Other indications for using botulinum toxin type A injection include spasm of the lower esophageal sphincter, excessive salivation and anal fissures (Aoki, 1998; Davis, 1993).

It is just unfortunate that botulinum toxin still needs to be considered as a bioweapon at the historic scene when it has become the prime biological toxin to become legal for treatment of human disease (Arnon, Inglesby, Henderson, Bartlett, & Ascher, 2001).

In another setting, the toxin is used as treatment for uncontrolled overactive muscular contractions (Jankovic, 1990). Another setting  in which the toxin is encountered is its cosmetic use for treating facial spasms and elimination of facial wrinkles for the temporary improvement of appearance (Sommer, Zschocke, & Bergfeld, 2003). Botulinum toxin injection provides useful symptomatic relief temporarily that lasts for weeks to months requiring repeated injections to sustain benefits over longer period of time (Blitzer, Binder, & Brin, 2000; Jankovic, 1990).

Diagnosis confirmation for botulism, serum, stool, and any leftover suspect food should be tested if any case positive of botulinum toxin. A mouse bioassay is an example of laboratory exam permormed. Injections of dilutions of sera from mice, stool, and food extract followed by injections of monovalent antitoxins A, B, and E and polyvalent antitoxin ABCEF, are then observed for signs of botulism and mortalities. Stool and food can also be cultured for the bacterium Clostridium botulinum, which produces the toxins.

Tests order for botulinum toxin and C. botulinum culture should contact the state health department. They can provide information about which specimens should be assayed or tested and how it should be stored, and will forward it to the state public health laboratory or to the Centers for Disease Control and Prevention (CDC) if the state does not have the resources to test for botulism (Botulism Poisoning Patient Scenario, 2004).

Botox

Numerous researches and studies done on C. botulinum paved the way to the identification and commercialization of botulinum toxin type A. Botox® is a trade name with a formulation of botulinum toxin type A  that is derived from the bacterium C. botulinum (Aoki, 1998).

BOTOX.RTM and Dysport.RTM are the two commercially available botulinum type A preparations used in humans. BOTOX. RTM available from Allergan, Inc in California.,while Dysport. RTM. is available from Beaufour Ipsen in England. These preparations consist of the purified form of botulinum toxin type A, albumin and sodium chloride (Aoki, 1998; Jankovic, 1990).

The botulinum toxin is injected directly into a specific muscle in extremely small amounts to block the release of the acetylcholine to alleviate muscle spasm as a result of too much neural activity (Jankovic, 1990; Mauskop, 2002; Rohrich, 2003; Silberstein, Mathew, Saper, & Jenkins, 2002).

FDA-approved Botox was first indicated for blepharospasm, followed by strabismus.  Due to the availability of better alternative therapy and very short duration of the effect, Botox is now rarely used for strabismus. In 1989, it began its wide use for dytsonia, dysphonia and torticollis (Aoki, 1998).

Botox and Dystonia

Cervical dystonia (spasmodic torticollis) is the main symptom of a neurological movement disorder causing severe involuntary movement of the neck and shoulder contractions (Giladi, 1997; Jankovic, 1990). Botulinum toxin type A injection is indicated to decrease the severity of abnormal head position such as tilting and associated neck pain with cervical dystonia

(Aoki, 1998; Jankovic, 1990).A low strength of botulinum toxin Type A is used therapeutically to relieve problems associated with muscle spasms (Jankovic, 1990). The principle behind any Botox therapy is once it is injected to the specific muscle, it results in paralysis of the local muscle only.  It is not systemic; therefore, surrounding muscles are still able to function properly.  This therapy takes advantage of the effect of the toxin as a muscle relaxant (Aoki, 1998). Botox blocks the nerve from releasing acetylcholine, thereby reducing or stopping muscle spasms and at the same time provides relief from the symptoms  (Giladi, 1997).

Botulinum toxin therapy is not actually a cure, but just an alternative to available treatments for different diseases (Jankovic, 1990).  The nerve takes about 90 days to recover and begins releasing acetylcholine again after this time. The more acetylcholine released the more active and tensed up are the muscles. At this point, another cycle of injection is necessary to provide relief (Giladi, 1997)

On the other hand, dysphonia is the term used that means a disorder of the voice. Spasmodic dysphonia is a laryngeal dystonia that outputs in altered speech. Spasmodic dysphonia usually occurs in the third decade of life and is much predominant in women (63%). There exist two types of spasmodic dysphonia, adductor dysphonia and abductor dysphonia. The diagnosis can be made with careful history and examination of the glottis with various laryngeal tasks (Cunningham, 2004).

Adductor dysphonia is the more common of the two types of spasmodic dysphonia. It accounts for 80% of all cases and is characterized by inappropriate glottal closure caused by hyperactivity of the thyroarytenoid muscles. This produces strain, harshness and strangled breaks in connected speech. Treatment of adductor dysphonia with botox is recognized as the primary treatment for the disorder by the American Academy of Otolaryngology-Head and Neck Surgery (Policy statement: Botulinum Toxin. Reaffirmed March 1, 1999)(Cunningham, Teller, Quinn, & Ryan, 2004).

Botox and Tension Headache

Headache is the most common complaint of patients seeking help from physicians. It is described to be a pain felt and experienced in the head, scalp, face, forehead or neck. Tension headache, which is classified under primary headache, is the most common headache not caused by other conditions. Tension type headaches are described as pain from the frontal to the occipital region (Mauskop, 2002; Relja, 2000)

Current research reports that botulinum toxin A can potentially relieve headache and migraine symptoms by numbing the neurotransmitters that cause headache pain. It is relatively up to 87 percent effective. This is the same medication therapy originally used for strabismus and cervical dystonia (Relja, 2000) and it is gaining acceptance among headache sufferers (Mauskop, 2002). In a study done by Dr. Richard Glogau, MD, results indicate that botulinum toxin A injected into the muscles of the brow, eyes, forehead, side of the head and back of the head near the neck provides immediate headache relief that lasts for up to 6 months (Glogau, 2003; Maquera, 2000).

Botox and Cosmetics

Injection of the botulinum toxin, known as Botox therapy to reduce wrinkles and rejuvenate the aging face has become very popular in adults younger than 65. Botox injections cause minor paralysis of facial muscles thus smoothing wrinkles for a period of time. A small amount of Botox injected into the muscles that are responsible for creating wrinkles inactivates the substance that causes it, thereby causing lines to disappear.

The effects are only temporary that last up to three to six months (Allergen, 2004; Aoki, 1998). With larger doses (600-900 U as used in cervical dystonia), generalized weakness has also been reported. The short duration of activity of BTX (10-12 weeks) implies automatically that the side effects are also transient and usually self-limiting requiring no more than reassurance. Anaphylaxis and rashes may be encountered occasionally (Bali and Thakur, 2005).

Generally, it is safe and well tolerated. The most common adverse effect is the extension of the effect outside the intended area. Though at lower doses, its effects are not much obvious, however no satisfactory solution to the condition of diffusion exists. Reports suggest that botulinum toxin B has lesser diffusion rates in animal trials but whether this will have any clinically potential effect in humans remains to be seen (Bali and Thakur, 2005).

Conclusion

According to (Vangelova, 1995), “botulinum toxin can heal as well as harm.” Botulinum toxin is a unique substance because although it is a toxin, it can also be safely used for resolving muscular contraction disorders and for wrinkle therapy (Allergen, 2004).

The extreme potency of botulinum toxin type A requires extreme caution in using this substance as a therapeutic agent. This neurotoxin can cause paralysis that can lead to death (Glogau, 2003). The same neurotoxin on the other hand can be safely used, in purified form for treatment and control of some medical conditions (Sommer, Zschocke, & Bergfeld, 2003).

The botulinum toxin is a safe and effective agent but is also potentially dangerous when misused by rogue nations and terrorists and should be taken seriously (Arnon, Inglesby, Henderson, Bartlett, & Ascher, 2001).

Despite of the many advantages botox has to offer, its wide utilization is still a big question to many. People are becoming more aware of the technologies from the use of botox, be it as a therapeutic agent or as a biowarfare. Scientists and researchers nevertheless, are furthermore conducting different studies and experiments regarding the potential of botox and its actual margin of safety for cure and its strength as a poison. Investigations are never ending. We may then actually wait for another discovery this organism has to crack for the people. Therefore, the answer to the big question, whether Clostridium botulinum is a friend or a foe, the answer is definitely both.

REFERENCES

1. AHW, H. (1989). Clostridium botulinum. In M. Doyle (Ed.), Foodborne bacterial pathogens (pp. 112–189.). New York: Marcel Dekker.
2. Allergen. (2004). Botox Cosmetic.   Retrieved November 10, 2006, from http://www.botoxcosmetic.net
3. Aoki, R. (1998). The development of BOTOX: its history and pharmacology. Pain Digest, 8, 337-341.
4. Arnon, S. S. (1980). Infant botulism. Annu. Rev. Med., 31, 541–560.
5. Arnon, S. S., Inglesby, T. V., Henderson, D. A., Bartlett, J. G., & Ascher, M. S. (2001). Botulism toxin as a biological weapon: medical and public health management. JAMA, 285, 1059-1070.
6. BALI J., T. R. (2005). POISON AS CURE: A CLINICAL REVIEW OF BOTULINUM TOXIN AS AN INVALUABLE DRUG. J. Venom. Anim. Toxins incl. Trop. Dis., V.11, n.4,, p. 412 – 421.
7. Bhidayasiri, R., Choi, Y. M., & Nishimura, R. (2004). Wound botulism. Postgrad Med J, 80(942), 240.
8. Blitzer, A., Binder, W. J., & Brin, M. F. (2000). Botulinum toxin injections for facial lines and wrinkles: Technique. In A. Blitzer, W. J. Blinder, J. B. Boyd & A. Carruthers (Eds.), Management of Facial Lines and Wrinkles (pp. 279-302). Philadelphia, PA: Lippincott Williams & Wilkins.
9. Botulism. (2003). Institute for International Cooperation in Animal Biologics An OIE Collaborating Center Iowa State University College of Veterinary Medicine.
10. Botulism Poisoning Patient Scenario.  (2004).).
11. Cassiday, T. (2007). UNMC expert: Bioterrorism agents used throughout history [Electronic Version]. Retrieved March 18, 2007 from http://www.unmc.edu/bioterrorism/history.htm.
12. Chia, J., Clark, J., Ryan, C., & Pollack, M. (1986). Botulism in an adult associated with food-borne intestinal infection with Clostridium botulinum. N. Engl. J. Med., 315, 239-241.
13. Cunningham, S. J., Teller, D., Quinn, F. B., & Ryan, M. W. (2004). Botulinum Therapy in the Laryngopharynx. Grand Rounds Presentation, UTMB, Dept. of Otolaryngology.
14. Davis, L. E. (1993). Botulinum toxin. From poison to medicine. West J Med, 158(1), 25-29.
15. Elad, D. (2006). Infant botulism. Isr Med Assoc J, 8(5), 365; author reply 365.
16. Erbguth, F. (1999). Historical aspects of botulinum toxin. Justinus Kerner (1786-1862) and the “sausage poison”. Neurology, 53, 1850-1853.
17. Freund, B. J. (2000). Treatment of chronic cervical-associated headache with botulinum toxin A: a pilot study. Headache: The Journal of Head and Face Pain, 40(3), 231-236.
18. Giladi, N. (1997). The mechanism of action of botulinum toxin type A in focal dystonia is most probably through its dual effect on efferent (motor) and afferent pathways at the injected site. J Neurol Sci, 152(2), 132-135.
19. Glogau, R. G. (2003). Botulinum toxin. In I. M. Freedberg (Ed.), Fitzpatrick’s Dermatology in General Medicine (6th ed., Vol. 2, pp. 2565–2567). New York: McGraw-Hill.
20. Henderson, D. (1999). The Looming Threat of Bioterrorism. Science, 283, 1279-1282.
21. Jankovic, J. (1990). Botulinum toxin injections for cervical dystonia. Neurology, 40, 277-280.
22. Maquera, V. (2000). Botulinum Toxin In The Treatment Of Headaches. Jacksonville Medicine.
23. Marvaud, J. C., Raffestin, S., & Popoff, M. R. (2002). [Botulism: the agent, mode of action of the botulinum neurotoxins, forms of acquisition, treatment and prevention]. C R Biol, 325(8), 863-878; discussion 879-883.
24. Mauskop, A. (2002). The Use of Botulinum Toxin in the Treatment of Headaches: Current Science, Inc.
25. Oguma, K., Fujinaga, Y., & Inoue, K. (1995). Structure and function of Clostridium botulinum toxins. Microbiol. Immunol, 39, 161-168.
26. Patocka, J., Splino, M., & Merka, V. (2005). Botulism and bioterrorism: how serious is this problem? Acta Medica (Hradec Kralove), 48(1), 23-28.
27. Prevention, C. f. D. C. a. (2001). botulism fact sheet. Retrieved March 20, 2007. from.
28. Relja, M. A. (2000). Treatment of tension-type headache with botulinum toxin: 1-year follow-up. Cephalalgia, 20, 336.
29. Risko, W. (2006). Infant botulism. Pediatr Rev, 27(1), 36-37.
30. Rohrich, R. J. (2003). The cosmetic use of botulinum toxin. Plastic and Reconsutructive Surgery, 112(5), 177S–191S.
31. Shapiro, R., Hathaway, C., & Swerdlow, D. L. (1998). Botulism in the United States: a clinical and epidemiologic review. Ann Intern Med, 129, 221-228.
32. Shukla, H., & Sharma, S. (2005). Clostridium botulinum: a bug with beauty and weapon. Crit Rev Microbiol, 31(1), 11-18.
33. Silberstein, Mathew, Saper, & Jenkins. (2002). Botulinum Toxin Type A as a Migraine Preventive Treatment. Headache: The Journal of Head and Face Pain 40(6), 445-450.
34. Simpson, L. (2004). Identification of the major steps in Botulinum toxin action. Annual Review of Pharmacology and Toxicology, 44, 167-193.
35. Sobel, J., Tucker, N., Sulka, A., McLaughlin, J., & Maslanka, S. Foodborne Botulism in the United States, 1990–2000. Atlanta, Georgia: Centers for Disease Control and Prevention.
36. Sommer, B., Zschocke, I., & Bergfeld, D. (2003). Satisfaction of patients after treatment of Botulinum toxin for dynamic facial lines. Dermatologic Surgery, 29, 456-460.
37. Stephen S. Arnon, M. R. S., MD; Thomas V. Inglesby, MD; Donald A. Henderson, MD, MPH; John G. Bartlett, MD; Michael S. Ascher, MD; Edward Eitzen, MD, MPH; Anne D. Fine, MD; Jerome Hauer, MPH; Marcelle Layton, MD; Scott Lillibridge, MD; Michael T. Osterholm, PhD, MPH; Tara O’Toole, MD, MPH; Gerald Parker, PhD, DVM; Trish M. Perl, MD, MSc; Philip K. Russell, MD; David L. Swerdlow, MD; Kevin Tonat, PhD, MPH; for the Working Group on Civilian Biodefense (2001). Botulinum Toxin as a Biological Weapon. JAMA The Journal of the American Medical Association, Vol. 285 No. 8.
38. Understanding the use of botulinum toxin in the treatment for dystonia. (2005). In A. a. I. P. Ltd. (Ed.). Chicago USA: Dystonia Medical Research Foundation.
39. Vangelova, L. (1995). Botulinum Toxin: A Poison That Can Heal.   Retrieved November 11, 2006, from http://www.fda.gov/fdac/features/095_bot.html
40. Weber, J. T. (1994). Wound botulism. Hosp Pract (Off Ed), 29(4), 16, 26.
41. Wells, C., & Wilkins, T. (1996). Clostridia: Sporeforming Anaerobic Bacilli. In S. Baron (Ed.), Medical Microbiology. 4th ed.  . Galveston (TX): University of Texas Medical Branch.
42. Wound botulism cases in injecting drug users. (2002). HPA Communicable Disease Surveillance Centre.