BOTULISM (Latin botulus sausage; synonym allantiazis) — the heavy intoxication resulting from consumption of the products containing Clostridium botulinum toxins, and which is characterized by preferential defeat central and the autonomic nervous system.
the Existing statistics does not reflect the true extent of incidence of people B. She is more reliable and stout where detailed laboratory inspection of all acute and fatal cases of diseases is carried out, and is practically absent in many countries where cases of death are not exposed to examination and there are no conditions for hospitalization of patients. Even in the developed countries only for the last decades this group of heavy intoxications began to be differentiated on types of the toxins which caused their development that is an indispensable condition for timely and correct treatment of the patient. Maier (To. Meyer, 1956), analyzing B.'s incidence in the world in 50 years, believes that for this period 5635 people from which 1714 died got sick.
This statistics is based on separate publications. In the USA in 65 years (1899 — 1964) 1574 diseased from whom 955 (60,6%) died are registered. In Russia from 1818 to 1913 it is reported about 609 sick B. which about half died. With improvement of the statistical accounting of incidence in our country from 1920 to 1939 it was known about 674 sick B. from which more fourth part died. In Japan from 1951 to 1964 297 sick B. from which 78 died are registered. In France before occupation by fascist troops 24 sick B. are registered; during occupation the number of the diseased exceeded 1 thousand people that as it appeared, it was connected with consumption of meat of the pigs slaughtered secretly in insanitary conditions.
the Causative agent of botulism Clostridium botulinum (a synonym of Bacillus botulinus) was described in 1896 Mr. Wang Ermengem (E. van Ermengem) during investigation of flash of B. in Germany. Studying of an etiology of B. in the next years showed that the disease is caused by several activators relating to one look. Six types of causative agents of botulism are known: And, B, C, D, E, F. Division into types is connected with an original antigenic structure of the exotoxin produced by a cell. Toxin of each type can be completely neutralized only by serum of homologous type.
Activators B. are eurysynusic in the nature. The dispute of these bacteria is the place of constant dwelling the soil from where they get to water, on fruit and vegetables, to foodstuff, fodder, and then to intestines of the person and animals (mammals, birds, fishes, invertebrates). Burke (G. Burke, 1919) at researches in California marked out 235 cultures from water, hay, the garden soil, insects, spiders, snails, horse manure, intestinal contents of birds. In all listed above objects activators B. form the disputes steady against influence chemical and physical. factors. Vegetative forms of activators B. perish at boiling within 2 — 5 min., sporous forms of some strains, especially types A, B, C, F, highly termorezistentna. They maintain 1 — 5-hour boiling and perish only during the autoclaving. Botulinum toxin partially collapses during the heating to t ° 70 — 90 °, at boiling within 5 — 15 min. collapses completely.
In our country in the environment types A, B, E most often meet, types C and F are more rare, at diseases at the person types A, B, E, are found in animals — types A, B, C, E.
All six Cl types. botulinum are very close on the morphological, cultural properties and on effect of their toxins on a human body and animals. They give an identical clinical picture of a disease.
Activators B. — strict anaerobe bacterias (see) and usually breed and form toxin in big pieces of fish, ham, sausage, in the closed canned food or on mediums in special devices — anaerobic jars. On liquid mediums growth of bacteria is followed by opacification of the environment and gas generation, there is a smell of rancid oil, but these signs are changeable.
The most characteristic property of all types of activators B. is their ability to develop in anaerobic conditions toxins (see). Force of toxins on artificial mediums, in various tinned foodstuff can make for ooze A and B from 10 thousand to 1 — 3 million in 1 ml of lethal doses for a white mouse. Dry and crystal botulinum toxins which contain in 1 mg to 100 million lethal doses for a mouse are received.
Activators B. of type E, and also not proteolytic strains of type B and some strains like F form on mediums and, perhaps, in foodstuff insufficiently active precursor of toxin — prototoxin which considerably increases the biological activity at hit in went. - kish. a path of the person and animals as a result of influence of proteolytic enzymes. At addition of trypsin, Pancreatinum of in vitro there is also an activation of prototoxin which passes in toksinony
On morphology activators B. — small sticks 4 — 9 microns long and 0,6 — 0,9 microns wide with the rounded-off ends (fig. 1). Sticks form subterminal or terminal disputes and have an appearance of a tennis racket (fig. 2 and 3). These microbes are easily painted by various aniline paints. Young cells are painted across Gram positively. In 4 — 5 days of growth of a stick are painted gramotritsatelno. Microbes are mobile, have from 4 to 35 flagellums (fig. 4), capsules do not form.
In crops in a high column of an agar microbes form colonies, shaped lentils (fig. 5) and lumps of cotton wool (fig. 6). At crops transparent colonies size in several millimeters with grow by a surface of a blood, hepatic or sugar agar equal (fig. 7) or the edges which are cut up (fig. 8) and a brilliant surface. On a blood agar of colony are surrounded with an active area (fig. 9).
Optimum temperature for growth of bacteria of types A, B, C, D is 34 — 35 °, for types Ε and F — temperature 26 — 30 °. See also Clostridium .
the Originality of epidemiology of B. is defined by the fact that it is not given from the sick person to healthy. The main tank of an infection at B. are hematothermal animals (preferential herbivorous), fishes, Crustacea, mollusks in which intestines Cl collect are more rare. botulinum which are allocated with excrements to the environment where pass into a sporous state. The subsequent germination a dispute on organic substrates in anaerobic conditions, especially in the range of temperature of 22 — 37 °, is followed by accumulation of microbes and their toxins.
Prevalence of diseases in the countries of the world is defined: obsemenennost disputes of Cl. botulinum of objects of the environment, degree of order of the person to toxin of this type, and also the nature of production (preparation) of foodstuff and feeding habits and life of the population. Absence in objects of the environment a dispute of Cl. botulinum, naturally, excludes a possibility of their hit in foodstuff, and the modern production technology them even in the presence a dispute prevents preservation or accumulation of botulinum toxin at storage of products.
Degree of order of the person to botulinum toxins of types A, B, C, D, E and F is inadequate. It is confirmed by the epidemiological data concerning spread of diseases and an obsemenennost of objects of the environment of disputes and also data on various sensitivity experimental and page - x. animals to different types of toxins.
Disputes of Cl. botulinum have a wide spread occurance. According to V. M. Berman (1941), «a source of botulism is all nature» that emphasizes a wide obsemenennost of objects of the environment with disputes of the activator. However the statistics of finds a dispute is insignificant. It has a talk the limited and directed searches connected with the arisen diseases or with need of inspection of certain territories from where vegetables or fish products for the food industry are delivered.
Improvement of methods of laboratory researches in the direction of detection of features of metabolism of the activator and wide use of type-specific serums allowed to establish an obsemenennost of the environment by various Cl types more authentically. and to present to botulinum modern geography of their distribution.
At a research of various samples taken in areas of the North Caucasus, the Azov and Caspian seas, Primorsky Krai, the Far East, Leningrad, disputes of the activator B. were found in 9% of tests of the soil and 4% of tests of water. At the same time in tests of the soil disputes of activators of types A, B, C and E, and in tests of water and silt type E are found. Among positive finds the type Ε made apprx. 74%; it met in the soil of coast of reservoirs of practically all inspected areas, the second place on the frequency of finds is taken by type B (16,5%), the third — type A (7,8%) and the fourth — type C (1,8%). In 33% of the studied tests of the soil of coast of the Lake Balkhash and some areas of the Armenian Soviet Socialist Republic disputes of the activator B are also found.
According to foreign researches, the most frequent finds a dispute of the activator B. take place at a research of beans (32%), the decaying plants (20%) and the overfermented green forages (20%).
In the analysis of incidence of B. that circumstance that all diseases are caused by three types of toxins — And, In and Ε with dominance of one of them in each certain country attracts attention. So, in the USA is more often than others the type A, in France and Norway — type B is B.'s reason, in Japan practically all diseases are connected with type E, in Canada type E prevails. In our country diseases are caused by three types of toxin (And, In and E). The diseases caused by toxins like C, D, F meet extremely seldom. One case of group poisoning (lake Chad) caused by toxin like
D is described. Also isolated cases of poisoning with toxin of type C are described. As for the activator producing toxin like F which is recently found in the USSR, the related diseases are registered only in Denmark and the USA one time.
Thus, inadequacy in pathology of botulinum toxins of various types is obvious. It is caused not so much by probability of hit in a human body of toxin of any type how many natural resistance of the person to one and high sensitivity to other types of toxins though there is an opinion (K. I. Matveev, 1959) that all hematothermal animals, W. h and the person, are equally sensitive to botulinum toxins of all types. However it is known that degree of order of hematothermal animals is not identical. To botulinum toxins pigs, dogs, wolves, foxes, wild and domestic cats, lions, tigers, and also many birds are high-resistant. These types are the «hospital attendants» destroying sick animals and drop, and character of their food represents exclusive opportunities of contacts with activators B. and their toxins. Horses whose character of food excludes the width of such contacts, and many laboratory animals are the most sensitive to botulinum toxins. This biological phenomenon consisting in various sensitivity of hematothermal animals to representatives of one group of toxins finds an explanation in evolutionary development of types and their relationship with activators B. In the course of this evolution a certain part of the individuals of a look possessing individual (but genotypic caused) ability to more resist to pathogenic effect of toxins, survived, transferring these features to the next generations. It must be assumed that also the far ancestors of the person using the crude and decaying meat had also the broadest contacts with activators B., and first of all with types C and D as with the most ancient representatives of klostridioz.
the Pathoanatomical changes found at necropsy of the patient who died from B. do not represent something specific. As a rule, the sharp hyperemia of all visceral bodies which is followed by multiple small and large hemorrhages is found. Covers of a brain are strongly hyperemic, hemorrhages meet. In tissue of a brain fibrinferments, defeats of an epithelium of vessels of necrotic and destructive character are found. Walls of vessels of tissue of brain are loosened. Ganglionic cells of a nervous system are most struck. Vacuolation of protoplasm, disintegration of a kernel is observed. The form of cells changes, shoots disappear, changes happen also in a neuroglia.
In heart of fiber of connecting fabric bulk up, the phenomena of a necrobiosis are observed. There is a fragmentation of a myocardium; striped striation disappears. Vessels are sharply overflowed with blood, swelling of an endothelium in capillaries and small vessels is found.
Lungs are filled with blood, are edematous. The picture of sharp hemorrhagic pneumonia is observed; in certain cases there is hepatization of certain sites of a lung, and sometimes and the whole shares. Capillaries of a lung are sharply expanded, in alveoluses accumulation of erythrocytes. The liver is full blood, is increased, brownish color, a flabby consistence. At microscopy granular regeneration of cells of hepatic fabric, fatty alteration, swelling of collagenic fibers of connecting fabric, dissociation of a hepatic parenchyma is noted.
In kidneys the epithelium of gyrose tubules, in direct tubules dystrophic changes is strongly changed.
The mucous membrane of a digestive tract is sharply hyperemic. The mucous membrane of a stomach which bulked up of yellowish color, is loosened, is very easily broken off, in it dot and larger hemorrhages are visible. Vessels of intestines are sharply injected and give to a serous cover the marble drawing; the mucous membrane of intestines which bulked up at microscopy is found vasodilatation, damage of a wall and an exit of erythrocytes.
From skeletal muscles muscles of a thorax, an abdominal wall and extremities most strongly are surprised. Muscles have «boiled», with a grayish shade a look; at microscopy vasodilatation, staz in capillaries is found, cross-striped striation disappears, fibers bulk up, have an appearance as at tsenkerovsky regeneration.
the Major pathogenetic factor at B. is botulinic toksinony according to a number of researchers, B.'s pathogeny has toxic character. It should be noted the important feature concerning genesis of intoxication toxin like E. On nutritious substrates this type of the activator B. forms toxin of smaller force, than activators of types A, B and F, however weight of intoxication and the lethality at B. of type Ε surpasses, as a rule, those at B. of types A, B and F. Existence of toxin Ε in two forms is the reason of such distinctions: prototoxin and toxin.
Low-active prototoxin, getting page foodstuff into a stomach, becomes more active enzymes, turns into toxin and already in an active state it is soaked up in intestines. Therefore release of a stomach from contents as an important medical action at the botulinic intoxication caused by toxin like E gains exclusive value.
Except a digestive tract, toxin can get also through respiratory tracts at inhalation of the dust supporting him. Also wound B.'s cases when disputes of Cl are known. botulinum got to a wound with the soil, there burgeoned, causing a disease, and also the case connected with transfusion of the cadaveric blood taken from the dead from B. (the disease at the dead was not distinguished).
Cl. botulinum are allocated from an organism with excrements, toxins — with urine, bile and excrements.
In an experiment at botulinic intoxication two important consistent patterns are determined: the first consists that single-step introduction of various types of toxin brings in a result to summation of toxic action; the second pattern is connected with a phenomenon of paradoxical sensitivity when repeated and frequent administration of toxin leads to a lethal outcome though the general dose did not exceed it a half of a lethal dose. It is established that botulinum toxin of type A selectively affects peripheral cholinergic nerve terminations while adrenergic fabrics are insensitive to it.
From blood toxin gets into bodies where strikes cells of various fabrics, first of all a nervous system, the most sensitive to botulinum toxins. Botulinic poison affects motor-neurons of the spinal motor centers and a myelencephalon that is the reason of development of a paralytic syndrome, and also peripheral motor neuromuscular devices, causing disturbance of transfer of excitement from a nerve on a muscle. At the same time there is no total block of momentum transfer. Besides, botulinum toxin in very high doses oppresses tissue respiration of a brain, but these changes are not a cause of death. Clinical observations and experimental data allow to consider botulinum toxin and vascular poison, to-rogo defeat of a nervous system of heart and vessels is the cornerstone of action. Short-term perfusion of toxin through vessels causes their spasm, long influence leads to paresis of vessels and fragility of capillaries.
Molecular mechanisms of interaction of toxins and a cell remain not deciphered.
the Postponed disease does not leave immunity. There are messages on recurrent diseases. So, K. M. Ayanyan (1967) observed B. at two children in 1963 and repeatedly at them in a year. Both children died. Both in the first, and for the second time Cl toxin was established. botulinum of type A.
The clinical picture
the Incubation interval 12 — 24 hours, but can be extended up to 10 days. The incubation interval is shorter, the disease is heavier. During flash cases both with short, and with longer incubation interval even are observed if persons ate at the same time same product. It, probably, is explained by uneven distribution of toxin in foodstuff, and also individual sensitivity of the diseased.
In most cases B. begins sharply. Symptoms can be shown in the form of three more often: main options: with dominance of dispeptic frustration, visual disturbances or respiratory function. At the first option the disease begins with feeling of nausea, vomiting quickly joins, edges can be only in an initial stage of a disease. Certain patients note skhvatkoobrazny, sometimes megalgias in epigastric area. The feeling of overflow and a raspiraniye of a stomach is often noted. At the same time dryness of mucous covers of an oral cavity develops, and patients feel strong thirst. The expressed meteorism, locks which as a result of paresis of intestines can be very resistant are characteristic. However in an initial stage of a disease the ease of a chair is quite often observed, at the same time fecal masses does not contain pathological impurity.
Symptoms of a dysphagia which in some cases develop already during the first hours diseases also are carried to precursory symptoms of B. Patients complain of existence of «lump» in a throat, morbidity during the swallowing, feeling of «scratching» behind a breast, the poperkhivaniye joins a bit later.
If the disease begins with visual disturbances, then patients quite often address the oculist. Originally they complain of «fog», «grid», «front sights» before eyes. Reading a usual font is complicated or it is impossible (paresis of accommodation), doubling of objects is less often observed.
At certain patients «acute far-sightedness» develops, edges there can be a korrigirovana the corresponding lenses. Visual disturbances in an initial stage of B. often proceed without dispeptic symptoms that complicates the diagnosis. At careful inspection of the patient, in addition to various visual disturbances, it is possible to establish existence of dryness in a mouth, I am eager, change of a timbre of a voice (an osiplost, a «rough» voice), and also symptoms of the general intoxication: headache, dizziness, general muscular weakness, bystry fatigue, sleeplessness. All these symptoms in an initial stage are not always rather accurately expressed or can be passed at survey in connection with sharp dominance of eye symptomatology. If the dispeptic option of initial manifestations of B. proceeds several hours, then visual disturbances without other characteristic displays of a disease can remain within several days.
The heaviest current of B. happens at initial development of respiratory frustration. Patients among full health begin to feel shortage of air, to do unexpected pauses during the conversation. Sometimes these pauses arise between separate syllables. There is a feeling of constraint or weight in a breast, in some cases there are thorax pains. Breath is usually not speeded up, but superficial. Along with disorders of breath the voice which becomes not only hoarse changes, but also gets a nasal shade. Disturbance of the act of swallowing quickly joins respiratory frustration. Symptoms of the general intoxication are always expressed: headache, sharp muscular weakness, dizziness, etc.
After initial manifestations of B. the disease enters a phase of the highest development of symptomatology. Subjectively patients note «fog», «grid», «flashing» or «front sights» before eyes. Contours of objects become indistinct. In attempt of reading a letter and line «run up». These symptoms develop owing to influence on a ciliary muscle of the toxin leading to its relaxation that leads to paralysis of accommodation. Doubling of objects is often observed, especially at turn of eyeglobes in the parties. In hard cases paralysis of one or several cranial nerves innervating muscles of an eye is observed ophthalmoplegia (see).
The expressed and permanent expansion of pupils — a mydriasis is almost always noted. This symptom appears one of the first and is longest remains. Inequality of pupils is quite often observed — anisocorias (see). Reaction of pupils to light is sharply reduced or in general is absent. Sometimes patients are not able to distinguish outlines of objects and perceive only photoirritations. It is often observed ptosis (see), quite often bilateral, however degree of a blepharoptosis can prevail on any one party. At heavier current of B. of an eye can be completely closed and to reveal them, patients are forced by hands to raise an upper eyelid.
Effect of botulinum toxin extends to the oculomotor and taking-away nerves, there is a disturbance of the movement of eyeglobes, there is a feeling of doubling of objects. Usually there is paresis of a lateral direct muscle of an eye earlier that leads to the meeting squint. In rare instances when paresis of a third cranial nerve prevails, the dispersing strabismus takes place. At a heavy current of B. simultaneous permanent damage of all oculomotor muscles is observed that leads to a full immovability of eyeglobes. At a number of patients it is possible to establish existence of a nystagmus, is more often than vertical.
Dysphagias are characteristic symptoms, but meet less than eye symptomatology. Patients complain of difficulty and morbidity during the swallowing in the beginning. Further they feel feeling of «lump» in a throat, and, at last, the act of swallowing is violated. The joined motor disturbance of language worsens the act of swallowing, changes an articulation. In hard cases of B. of the patient is not able to move a tip of language too much of teeth. The developing paresis of an epiglottis leads to incomplete closing of respiratory tracts during the swallowing that creates a possibility of hit of food in respiratory tracts, causing a poperkhivaniye, fits of coughing and suffocation.
At patients with frustration of the act of swallowing lack of a gag reflex is observed, it is possible to note the phenomena of paresis of a soft palate. In hard cases the palatine velum is not mobile, hangs down on a root of language. In attempt to swallow water it follows through a nose.
During the first hours diseases decrease in a timbre of a voice and an osiplost is noted that it is connected with decrease in a sialosis and dryness of phonatory bands. In process of development of paresis the indistinct articulation («lumps in a mouth») and twang join these symptoms, and with development of paresis of phonatory bands there can come the full aphonia.
Less often at sick B. sluggish paresis of facial muscles owing to defeat of the VII pair of cranial nerves is noted. From the first hours at patients the sharp myasthenia develops, edges disturbs the patient throughout the entire period of intoxication. At the same time at B. there is never a defeat of the sensitive sphere, and also a loss of consciousness.
At a heavy current of B. development of paresis of respiratory muscles is characteristic that is expressed in lack of diaphragmal respiration, sharp restriction of mobility of intercostal muscles, disappearance of a tussive reflex. Frustration and apnoea are one of the main reasons for death at B. Respiratory insufficiency accepts especially heavy current also because along with paresis of respiratory muscles inflammatory processes in lungs, as a rule, are found in patients. In an onset of the illness patients note «shortage» of air, feeling of constraint and weight in a breast, quickly are tired during the conversation or do unexpected pauses deeply to sigh. The respiration rate can reach 30 — 40 in 1 min., pathological types of breath are noted further.
The cardiovascular system suffers for the second time, because of intoxication, at heavier disease (tachycardia, muting of cordial tones, sometimes expansion of limits of relative dullness of heart, systolic noise at its top, symptoms of dystrophy of a myocardium according to an electrocardiography). Arterial pressure, both systolic, and diastolic, has a nek-ry tendency to increase that connect with vasoconstrictive effect of toxin.
At B. body temperature does not increase, but at severe forms of a disease the hyperthermia both in initial stages, and in later period is possible. However fervescence at sick B. in the late period of a disease is caused by accession of pneumonia more often.
At a part of patients the oliguria, decrease in specific weight of urine, an albuminuria is noted. In draft hyaline and granular cylinders, erythrocytes. Level of residual nitrogen of blood can exceed normal values.
In blood the leukocytosis with a neutrocytosis and emergence of young forms of neutrophils (is more often noted moderated (sometimes and considerable) at severe forms of a disease).
At disturbances of swallowing — aspiration pneumonia. At recovering the miozita which are followed by pains and difficulties of movements and infectious myocarditis can be observed. Development of a myopia is possible.
the Diagnosis is made on the basis of the given the anamnesis, clinical and laboratory trials.
Laboratory diagnosis is based on detection of botulinum toxin or the activator B. in the materials taken from the patient (blood, emetic mass, rinsing waters of a stomach, kcal, etc.), and also in foodstuff which caused poisoning. It is important to establish not only presence of toxin or a microbe, but also to define its type to confirm the clinical diagnosis and to appoint the correct treatment.
Blood it is necessary to take to lay down before introduction to the patient. serums. In the samples taken for laboratory researches and also in foodstuff, it is impossible to add the preserving substances. Materials shall be stored in the refrigerator.
The tests which came to laboratory are investigated at the same time in two directions: two thirds of previously prepared test (receive a filtrate or tsentrifugat) intend for detection of botulinum toxins in a neutralization test, one third — for crops for the purpose of allocation of botulinic microbes.
For detection of toxin for each test take 4 mice weighing 16 — 18 g. Because in the studied material there can be one of six types of botulinum toxins, preliminary reaction needs to be put with mix of antibotulinic diagnostic serums of all types. It is impossible to use medical antibotulinic serums for diagnosis. From each studied test pour in two test tubes equal quantity (on 1,5 — 2,4 ml) a filtrate or a tsentrifugat. To the one (first) test tube (control) add 0,6 ml of normal saline solution, to another (experience) — 0,6 ml of mix of monovalent serums then contents of the first test tube are entered to two white mice intraperitoneally or into a vein of 0,7 — 1,0 ml, test tubes (experience) enter the same volume of the second to the second couple of white mice. The studied material from each test tube should be entered different syringes.
Overseeing by animals is conducted within 4 days, however if mice are ill or perish before this term then the neutralization test with monovalent diagnostic serums is put.
In the presence two mice die in test of botulinum toxin, the Crimea was entered a filtrate without serums, other two survive. Usually the picture of a disease and death of mice is very characteristic: there is hurried breathing, a condition of full relaxation of muscles, retraction of muscles of an abdominal wall («wasp waist» — fig. 10), paralyzes and spasms before death.
In case of death of all 4 mice it is necessary to repeat a neutralization test with the extracts divorced in 5, 10, 20, 100 times. At cultivation of extracts foreign microflora loses ability to kill mice, and botulinum toxin, having usually bigger biological activity, will cause death of mice at cultivation of filtrates.
In case of detection in reaction with polyvalent serum of botulinum toxin the developed neutralization test for definition like toxin with type-specific diagnostic serums is at once put.
Special attention needs to be paid on statement of a neutralization test with blood serum of the patient since she usually is a little. It is necessary to separate carefully serum from a clot and at once to put the developed neutralization test with monovalent botulinic serums of types A, B, E (other types B. meet very seldom).
During the receiving a positive neutralization test with diagnostic botulinic serums the conclusion about existence in the studied material of botulinum toxin is drawn and its type is specified.
Quite often statement of a neutralization test both with polyvalent, and with monovalent serums it is necessary to repeat because of nonspecific toxicity of foreign microflora, edges usually there is in emetic masses, Calais therefore at best the answer about availability of toxin in test can be given on 2 — the 3rd day, and about its standard accessory — on 3 — the 5th day from the beginning of a research.
In case of impossibility of detection of toxin in the studied materials researches on detection of the activator B are conducted.
Crops of 3 — 5 ml of the prepared material on liquid mediums are for this purpose made. For primary crops it is better to use casein and mushroom or casein acid condition, Hottinger's broth or Wednesday like Tarozzi. It is necessary that pH was within 7,2 — 7,4. Also existence in meat environments of meat or liver forcemeat, and in casein — boiled millet and cotton wool is obligatory. The test tube or a bottle shall be filled with a medium not less than half. Before crops on Wednesdays add 0,5% of glucose.
Crops shall be made on Wednesdays in big test tubes or in bottles with a capacity of 100 — 200 ml. From above Wednesday is filled in with a layer of a liquid paraffin 0,5 cm thick. It is necessary to remember that it is better to sow an initial inoculum in the large volume of the environment (70 — 150 ml) that cultural liquid of primary crops was enough for all researches especially. The subsequent resowings of the studied tests from primary crops in the same liquid mediums can not give toxin productions in the environment. Crops should be made in four bottles, two of which warm up at t ° 80 ° 20 min. Two other bottles after crops do not warm up. All bottles place in the thermostat at t ° 28 and 35 ° (in each thermostat one heated-up, one not heated-up).
If in the studied material activators B. are preferential in a vegetative form, then growth in crops will be hl. obr. in not heated-up bottles. In the same case if in material the sporous forms are had, growth will be in heated-up bottles and in some cases can lead to release of pure growth from such crops at once.
In 48 hours from the beginning of growth from all bottles with respect for sterility take samples of cultural liquid (on 10 — 15 ml) and subject them to a research. With cultural liquid the neutralization test with polyvalent antibotulinic serum is put. During the receiving positive takes the neutralization test is put with each type-specific serum separately. If in two days in bottles growth is not found, then it is necessary to continue an incubation in the thermostat, and to conduct a research on 4 — 6 — the 10th days. At detection in the studied crops of the sticks typical on morphology for Cl. botulinum, and also botulinum toxin the conclusion about infectiousness of the studied material is drawn by the activator B. Release of pure growth in that case is not obligatory.
If in crops microbes, on morphology similar to Cl are found. botulinum, and toxin is absent, it is necessary to carry out activation of cultural liquid by Pancreatinum or trypsin.
The activator B., decisive for the answer about infectiousness of the studied material, and its type are these neutralization tests. In doubtful cases make allocation (from a high column of an agar, from crops on Petri dishes) pure growth. The separate colonies characteristic on morphology of Cl. botulinum, sow on fluid mediums and investigate in 3 — 5 days of growth in a neutralization test with type-specific antibotulinic serums.
The neutralization test is reliable, highly specific and rather sensitive method of detection of botulinum toxins.
Other offered methods of laboratory diagnosis of B. (reaction of passive hemagglutination, a method of calculation of a phagocytal index, the luminescing serums) are especially experimental and in broad practice are not applied because of insufficient specificity.
The differential diagnosis
B. should be differentiated with poisoning with a henbane. Unlike B., the first symptoms of poisoning come in 1 — 5 hour after consumption of a plant. Weakness, drowsiness, dizziness, a headache is noted. There can be nausea, seldom vomiting. Integuments of the person and trunk are hyperemic, scarlatiniform rash sometimes is found. Looking alike of B. consists in permanent expansion of pupils and lack of their reaction to light, dryness of mucous membranes of a mouth, disturbance of a sialosis. Frustration of mentality are naturally observed. Patients are usually very uneasy, their movements are not coordinate, inadequate reaction to the surrounding phenomena, nonsense is observed, is more often with considerable hallucinations. There can be kloniko-tonic spasms. Tachycardia, disturbance of a rhythm, a lowering of arterial pressure, dullness of cordial tones is noted. At development of a coma sharp pallor of integuments, bradycardia, short wind, frustration of a respiratory rhythm is observed. Death comes from an apnoea.
Poisoning with methyl alcohol the general weakness, a ring in ears, nausea, vomiting, sometimes also leads abdominal pains to development of a number of the symptoms similar to B. Otmechayetsya. Pupils are expanded and badly react to light. Vision disorders have dvukhvolnovy character. At first patients note flashings before eyes, decrease in visual acuity, «fog», doubling of objects; then there can occur a nek-swarm improvement of sight then the blindness develops that is not observed at B. V hard cases of poisoning hallucinations are noted, the fear, spasms, weakening of an animal force, a loss of consciousness, falling of cardiovascular activity, but paresis are not observed.
At differential diagnosis with poisoning with poisonous mushrooms it is necessary to consider that B. usually arises at consumption of tinned mushrooms while poisoning with poisonous mushrooms occurs more often at the use of freshly cooked mushrooms.
At the poisoning with a fly agaric connected first of all with effect of the muscarine possessing atropinopodobny action, a muskaridina and a piltstoksina strong hypersalivation, sweating, a profuse diarrhea, kolikoobrazny abdominal pains, delay of pulse, blanching of the person, permanent expansion of pupils is noted (the last reminds B.). In more hard cases hallucinations (more often visual), reddening of integuments of the person and a spasm are noted.
Early approach of respiratory frustration at a number of patients with poliomyelitis can be mistakenly regarded as B too. Unlike B., at poliomyelitis the plentiful slizeotdeleniye and a sialosis takes place.
For the differential diagnosis with diphtheria changes in a pharynx — diphtheritic plaques matter. Neurologic frustration at diphtheria usually arise after quinsy, fervescence, puffiness of hypodermic cellulose. Paralyzes come along with development of myocarditis more often.
Forecast at B. always heavy. Active and only an early serotherapy and use of artificial hardware respiration that patients who were fateful earlier manage to save life even. Recovery happens slowly, usually within a month and more. Working capacity is recovered is longer; the myopia which arose in the acute period of a disease remains also long.
Patients are subject to unconditional hospitalization. It is necessary to carry out urgently a gastric lavage and to clear intestines. It is necessary to consider that the gastric lavage at B. is rather difficult since due to the lack at a sick gag reflex and existence of paresis of an epiglottis hit of the probe in respiratory tracts is possible. Before washing it is necessary to be convinced precisely that the probe is in a stomach.
For the purpose of neutralization of the botulinum toxin which is freely circulating in blood use of antibotulinic serums is necessary. Their introduction in the first days of a disease since the highest concentration of toxin in blood is observed on 2 — 3-p days of a disease (L. M. Shvedov, 1960) is the most effective.
However, considering a possibility of long intake of toxin in blood of the patient, it is possible to consider what to lay down. the effect of serumal therapy will be expressed also in later terms of a disease. In cases when the type of the toxin which caused a disease is still unknown introduction of all four types of serum is necessary (And, In, With, E). After establishment like the activator enter serum of the corresponding type. It is necessary to consider that poisoning with several types of toxin is possible. Serum can be entered both intravenously, and intramusculary. Serum like A — 10 000 ME, type B — 5000 ME, type C — 10000 ME, type E — 10 000 ME is originally entered. However quite often this quantity happens insufficiently for full neutralization of toxin. The subsequent administrations of serum are possible, doses a cut will depend on clinical effect. Usually for treatment of severe forms of B. about 50 000 — 60 000 ME of types A, C, Ε and 25 000 — 30 000 ME of V type are spent for a full course of treatment. However and these doses can be increased.
The general complex of treatment of sick B. includes nonspecific disintoxication therapy, edges it consists of introduction of saline solutions, glucose and blood substitutes. Especially favorable influence low-molecular solutions — Haemodesum, polyvinylpirrolidone, and also a blood plasma possess.
Considering a possibility of vegetation of the activator from a dispute in went. - kish. a path of the patient, many clinical physicians recommend use of levomycetinum or drugs of a tetracycline row. Duration of treatment is 7 — 8 days. Using antibiotics the frequency of «exacerbations» of a disease was reduced.
For the purpose of reduction of terms of recovery of disturbances from a nervous system purpose of ATP in the form of 1% of solution on 2 ml three times a day within 7 — 10 days is shown.
Defeat of cardiovascular system demands use of camphor, Cordiaminum, cardiac glycosides.
The patient shall receive to lay down. doses of vitamins, first of all from groups C and B.
A specific place in treatment of patients is held by questions of fight against disorders of breath. Use of artificial hardware respiration is justified. Respiratory resuscitation at B. consists of elimination of obstruction of respiratory tracts and creation of adequate lung ventilation by means of respirators.
Indications for imposing of a tracheostoma and endotracheal artificial ventilation at B. is paresis of muscles of a throat, throat and language with complaints to the complicated breath, paresis of respiratory muscles with decrease in vital capacity of lungs to 30%, weakening of a tussive reflex, atelectases and inflammatory processes in lungs. It is recommended to use the devices which are adjusted on volume with an independent respiration rate.
Despite reduction of a sialosis, the patient needs to carry out periodically suction of the slime accumulating in upper respiratory tracts.
At development of pneumonia by the patient the corresponding antibiotic therapy is necessary.
In a stage of late reconvalescence physiotherapeutic procedures can be applied to treatment of paresis with success.
in process of improvement of technology of processing of foodstuff at optimum temperature schedules of B. among people, connected with use for food of products of industrial production, practically disappears. The main place as an origin of a disease in many countries of the world and in the USSR occupy various foodstuff of house preparation (tinned, marinated, smoked, dried, etc.). However in the USA in 1963 from commercial products B. 25 people ached, 9 of which died. In Japan B. is connected with the use of a national dish of «izusha», a component to-rogo crude fish is, Eskimos of Alaska have dishes from meat of a white whale, Indians on the coast of the Pacific Ocean of North America have calves of a salmon. According to the data which are of historical interest till 1964 in the USA the main source of B. were badly sterilized or marinated vegetables and fruit containing insufficient percent of acid. In France, Denmark, Norway, Sweden, Yugoslavia and other countries of Europe B. connected hl. obr. with ham and fish of house preparation.
Knowledge of optimal conditions of germination a dispute, their resistance to influence of temperature, and also conditions of toxin production, allows to define accurately the main requirements to processes of technological processing of foodstuff excluding a possibility of accumulation in them of botulinum toxins. Treat such requirements: protection of products from pollution by disputes of activators B., the heat treatment of products providing death a dispute (sterilization), vegetative cells and destruction of toxin, an exception of a possibility of germination a dispute and toxin productions in a ready-made product.
Need of the maximum barrier of products from hit in them a dispute or obligatory removal them during the cleaning and washing with running water (vegetables, fruit, mushrooms) is defined by broad planting of objects of external environment this activator. In relation to meat and fish products release from a dispute is carried out by accurate and bystry removal of intestines at postlethal cutting of hulks and fishes, especially red, immediately after a catch.
At the same time immediate cooling of products after their cleaning and washing as further technological operations, such as conservation, the ambassador, smoking and pickling, cannot destroy the toxin formed for shelf-life of products in heat is absolutely obligatory, and used for conservation or pickling of substance (sodium chloride, sugar, acids) are only capable to detain further toxin production.
The correct temperature schedule in processing of products has exclusive value. Usual thermal treatment of the products intended for direct use can be effective only on condition of their implementation during the first hours as, destroying toxin at usual conditions of heating to 100 °, it does not break viability a dispute. At gradual cooling and long storage at the room temperature in such products toxin at the expense of sprouted a dispute in vegetative cells can collect. It is obvious that repeated thermal treatment of such products before the use is obligatory.
Sterilization of products shall be carried out only in autoclaves where the corresponding elevated pressure allows to create temperature 120 °, having pernicious effect not only on vegetative cells and their toxins, but also on disputes. Such products released by the industry are harmless even in case of long-term storage at the room temperature. This situation cannot extend to canned food of house preparation since temperature influence at the same time does not exceed 100 °, and sealing of cans creates optimal anaerobic conditions for germination remained a dispute, vegetations and toxin productions in food substrate. Therefore in house conditions in the absence of the autoclave it is impossible to preserve the meat and fish products which are a good medium in hermetic jars. This situation completely extends to conservation of mushrooms and vegetables which cannot absolutely be released from a dispute of the activator B. Such products are admissible to be prepared for the future only by pickling or a pickles with addition of enough acid and salt and it is obligatory in open for access of air to a container.
External manifestation of infectiousness of canned food disputes of activators B. and their development in substrate of canned food is the gas generation leading to a bombazh of a container (inflation of covers). At the same time canned food is softened, their structure changes, appears off-flavor. However cases when botulinum toxin was found in externally not changed canned food are described.
For the prevention of diseases of B. technological processes at the food enterprises where preserved foods are made, are strictly regulated by the corresponding instructions from which rejections are inadmissible.
In relation to a type of raw materials or products there are rigid conditions which possibilities of execution define readiness of this enterprise for release of high-quality products. Such requirements exist to production of dairy products, to processing of vegetables, fruit and raw materials from greens, to processing of mushrooms, to preparation of various marinades, spices, spices and other substances used for conservation. Rigid conditions are imposed also to cans, preparation them to filling and control of their tightness. Guarantee of release by the enterprise of high-quality products are: good dignity. a condition of the equipment of the plant, use for the technological purposes of drinking water, free from anaerobic microorganisms, a careful sink of raw materials and processing of supporting materials, observance of the modes of processing excluding development in products of the activator B., establishment of the regulated acidity of products, use only of a tight container at constant control of operation of zakatochny machines, use of the modes of sterilization guaranteeing full neutralization of canned food (destruction of toxin, death of vegetative cells and a dispute).
Exclusively effective remedy of specific prevention of B. at the person is vaccination by botulinic polyanatoxin. Considering exoticism of incidence of B. in the USSR this means has no broad use and is used only in cases of protection of personnel of the laboratories conducting researches with the activator B.
Botulism in the medicolegal relation
For expert diagnosis of poisoning with botulinum toxin it is necessary to have investigative data on conditions of developing of poisoning (character of the products eaten the number of victims, the noticed symptoms, medical documents on assistance). The forensic scientist shall mean idiosyncrasies of clinic of poisoning. At a research of a corpse of changes, specific to B., is not established; the picture of quickly come death is usually observed. The histologic research is obligatory, at Krom the picture of a circulatory disturbance, a paretic condition of capillaries and perivascular hemorrhages in c comes to light. N of page, degenerative changes of nervous cells (hl. obr. in kernels of third cranial nerves, in a myelencephalon and a chetverokholmiya). Also paretic condition of small vessels in a wall of a small and large intestine, in lungs, a myocardium can be observed. Besides, on court. - the chemical research is directed by bodies (by the general rules), and on bacteriological — blood, food masses, rinsing waters, urine, the remained foodstuff.
A final conclusion about poisoning with botulinum toxin court. - the medical expert makes on set of all obtained data.
Bibliography: Burgasov P. N. and Rumyantsev G. H. Evolution of botulism, Zhurn, mikr., epid, and immun., No. 9, page 18, No. 11, page 79, 1967, No. 1, page 73, No. 2, page 83, No. 4, page 3, 1968; Kravchenko A. T. ishishulina of JI. M. Distribution of causative agents of botulism and tetanus in the territory of the USSR, M., 1970, bibliogr.; Matveev K. I. Botulism, M., 1959, bibliogr.; V. N. millers and N. I. Millers. Mephitic gangrenes, page 171, M., 1973; In about about f f D. And. a. D a s Gupta V. of R. Botulinum toxin, in book: Microbialtoxins, ed. by S. Kadis a. o., v. 11-A, p. 1, N. Y. — L., 1971, bibliogr.; Botulism, ed. by Κ. H. Lewis a. K. Cassel, Cincinnati, 1964; Botulism, ed. by M. Ingram a. T. A. Roberts, L., 1967; Burke G. S. Occurence of bacillus botulinus in nature, J. Bact., v. 4, p. 541, 1919; Dolman of Page E. Human botulism in Canada, Canad. med. Ass. J., v. 68, p. 538, 1953; Meyer K. F. The status of botulism as a world health, Bull. Wld Hlth Org., v. 15, p. 281, 1956.
P.N. Burgasov, V. I. Pokrovsky, S. G. Pak; T. I. Bulatova (etiol., laboratory diagnosis), V. K. Derboglav (court. medical).