Foodborne botulism outbreak with potential new management options

Ali H. Altalag; Mohammed A. Badawee; Sahar A. Hassan; Nahla A. Habiballa; Naif M. Alotaibi; Ehab A. Ahmed; Mohammed N. Aljuaid; Muhammad A. Almalki; Ahmed A. Alahmari; Adulrahman A. Alshehri

doi:10.15537/smj.2024.45.6.20240419

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Figure 1
- Home-made and home-stored canned food (pickles).
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Figure 2
- Statistics of cases in Riyadh as of May 3, 2024 as per announcement carried out by Ministry of Health on that date. KSA: Kingdom of Saudi Arabia, ICU: intensive care unit, Lab.: Laboratory
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Figure 3
- Statistics of cases in Prince Sultan Military Medical City, Riyadh, Saudi Arabia, as of May 13, 2024.PSMMC: Prince Sultan Military Medical City, No.: number, ICU: intensive care unit

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Table 1

- Demographic data, presentation, clinical features, management, disease severity, and outcome of all 13 cases.

Variables	Patient 1	Patient 2	Patient 3	Patient 4	Patient 5	Patient 6	Patient 7	Patient 8	Patient 9	Patient 10	Patient 11	Patient 12	Patient 13
Demographics
Age (years)	34	20	25	22	22	28	43	21	20	23	29	25	18
Gender	F	M	M	F	M	F	M	F	M	M	F	M	M
Nationality	Philipino	Saudi	Saudi	Saudi	Saudi	Saudi	Saudi	Saudi	Saudi	Saudi	Saudi	Saudi	Saudi
Weight (kgs)	60	71	116	71	73	60	85	81	80	78	120	55	66
Co-morbidities	Mild scoliosis	None	Obesity	None	None	None	Smoker/ diabetic	None	Smoker	None	Obesity/asthma	Gilbert syndrome	Bronchial asthma
Presentation (year 2024)
Possible source	Source-1	Source-1	Source-1	Source-1	Source-1	Source-2	Source-1	Source-2	Random	Random	Random	Source-2	Random
Date of exposure	April 14	April 21	April 23	April 25	April 25	April 24	April 25	April 26	April 30	April 30	April 30	April 30	May 4
Onset of symptoms	April 17	April 22	April 24	April 25	April 26	April 25	April 26	April 27	April 30	May 1	May 1	May 2	May 4
ER presentation	April 18	April 23	April 24	April 26	April 27	April 28	April 28	April 29	April 30	May 1	May 1	May 2	May 5
RRT activation	April 20	April 23	April 24	April 26	None	April 28	April 28	April 29	April 30	May 1	May 1	May 2	May 5
Clinical features
Dyspghagia	✔︎	✔︎		✔︎	✔︎	✔︎	✔︎		✔︎	✔︎	✔︎	✔︎	✔︎
Visual symptoms^*				✔︎		✔︎	✔︎	✔︎	✔︎	✔︎	✔︎	✔︎	✔︎
Speech symptoms	✔︎	✔︎	✔︎			✔︎	✔︎		✔︎			✔︎
UL weakness	✔︎	✔︎		✔︎		✔︎			✔︎	✔︎	✔︎	✔︎	✔︎
LL weakness	✔︎			✔︎					✔︎	✔︎	✔︎	✔︎	✔︎
Respiratory symptoms		✔︎	✔︎	✔︎	✔︎	✔︎		✔︎	✔︎
GI symptoms	✔︎				✔︎		✔︎		✔︎	✔︎	✔︎	✔︎	✔︎
Headach				✔︎	✔︎			✔︎
Dizziness		✔︎		✔︎						✔︎	✔︎		✔︎
Days from presentation to diagnosis	7	3	4	0	0	0	0	0	0	0	0	0	0
Differential diagnosis	GBS	MG/GBS	MG				GBS			GBS	GBS
IVIG
IVIG given	✔︎	✔︎	✔︎	✔︎		✔︎	✔︎	✔︎
Improvement after IVIG	✔︎							✔︎
Antitoxin
Days from presentation to antitoxic	7	3	4	0	0	0	0	0	0	0	1	0	0
Improvement after antitoxin	✔︎		✔︎	✔︎	✔︎	✔︎	✔︎	✔︎	✔︎	✔︎	✔︎	✔︎	✔︎
Adverse reactions to antitoxin	None	None	None	None	None	None	None	None	None	None	None	None	None
3,4-DAP
Days from presentation to 3,4-DAP	7	3	4	1	None	0	0	0	0	0	1	0	0
Improvement after 3,4-DAP	✔︎		✔︎	✔︎			✔︎	✔︎	✔︎	✔︎	✔︎	✔︎	✔︎
Adverse reactions to 3,4-DAP	None	HTN	Tachycardia/HTN	None	-	None	None	None	None	None	None	None	None
Severity and outcome
MV		✔︎
NIV							✔︎
HFNC			✔︎				✔︎
ICU LOS (days)	5	Still in ICU	9	9	0	8	2	3	2	4	3	2	2
Discharged	✔︎	Still in ICU	✔︎	✔︎	✔︎	✔︎	✔︎	✔︎	✔︎	In rehab	✔︎	✔︎	✔︎
Hospital LOS (days)	19	Still in ICU	13	10	2	10	6	6	2	In rehab	4	3	2

↵* Visual symptoms include: ptosis, double vision and blurring of vision.
M: male, F: female, ER: emergency room, RRT: rapid response team, UL: upper limb, LL: lower limb, GI: gastrointestinal, GBS: Guillain-Barré syndrome, MG: myasthenia gravis, IVIG: intravenous immunoglobulin, 3,4-DAP: 3,4-diaminopyridine, HTN: hypertension, MV: mechanical ventilation, NIV: non-invasive ventilation, HFNC: high flow nasal cannula, ICU: intensive care unit, LOS: length of stay, rehab: rehabilitation

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Table 2

- Clinical, management, and outcome data of study cases.

Variables	n (%)
Total number of patients	13 (100)
Demographics
Age (<30 years)	11 (85.0)
Male	8 (62.0)
Female	5 (38.0)
Co-morbidities	6 (46.0)
Source of poisoning
Source-1	6 (46.0)
Source-2	3 (23.0)
Random source	4 (31.0)
Clinical presentation
Incubation period	Few hours - 48 hours
Dyspghagia	11 (85.0)
Visual symptoms	9 (69.0)
Speech symptoms	7 (54.0)
UL weakness	9 (69.0)
LL weakness	7 (54.0)
Respiratory symptoms	7 (54.0)
GI symptoms	8 (62.0)
Headach	3 (23.0)
Dizziness	5 (38.0)
IVIG
Patients received IVIG	7 (54.0)
Improvement after IVIG	2 (29.0)
Antitoxin
Patients received antitoxin	13 (100)
Improvement after antitoxin	12 (92.0)
Adverse reactions to antitoxin	0 (0.0)
3,4-DAP
Patients received 3,4-DAP	12 (92.0)
Improvement after 3,4-DAP	10 (83.0)
Adverse reactions to 3,4-DAP	2 (17.0)
Disease severity and outcome
Patients required ICU care	12 (92.0)
Patient required MV	1 (8.0)
Patient required NIV	1 (8.0)
Patient required HFNC	2 (15.0)
Patients discharged home	11 (85.0)
ICU LOS^*	4 (2-9) days
Hospital LOS^{^†}	7 (2-19) days

UL: upper limb, LL: lower limb, GI: gastrointestinal, IVIG: intravenous immunoglobulin, 3,4-DAP: 3,4-diaminopyridine, MV: mechanical ventilation, NIV: non-invasive ventilation, HFNC: high flow nasal cannula, LOS: length of stay