FMMS PRIMER ON BIOTERRORISM

General Discussion

Biological toxins are products of living organisms, which produce illness or death after aerosol inhalation or ingestion. Substances are non-volatile and not likely to produce secondary person-person exposure - use Standard Precautions.

Botulinum Toxin

• (Types A-G) Most poisonous substance known. Botulinum toxin prevents release of acetylcholine at presynaptic nerve terminal and blocks nerve transmission. Aerosolized or food borne, typically presents 12-72 hours after exposure
• Symptoms
  • 4D's - diplopia, dysarthria, dysphonia, dysphagia.
  • Ptosis, mydriasis, generalized weakness, dizziness, dry mouth and throat, blurred vision, respiratory failure.
  • Naturally occurring food-borne botulism more prone to preceding abdominal cramps, nausea, vomiting and diarrhea secondary to other bacterial metabolites in food.
• Clinical Diagnosis
  • Symmetrical descending flaccid paralysis with prominent bulbar palsies,
  • Afebrile
  • Clear sensorium.
• Differential Diagnosis
  • Guillain-Barre,
  • Myasthenia gravis,
  • Tick paralysis,
  • Conversion reaction
• Action
  • Call public health department,
  • Draw at least 30cc blood (red top),
  • Sample feces, gastric secretions or vomitus.
  • Refrigerate samples and submit any suspect food.
  • Send list of patient's medications with samples.
  • Mouse neutralization assay can confirm diagnosis.
• Decontamination
  • If suspected aerosol release, breathe through clothing.
  • Intact skin is impermeable, but wash skin with 0.1% hypochlorite or soap/water.
  • Persistence of aerosolized toxin is dependent on atmospheric conditions and is usually inactivated by 2days.
  • In food, the toxin is inactivated by heat.
• Treatment
  • Botulinum antitoxin (to be used at first signs of illness) will minimize severity, but not reverse existent paralysis. Paralysis can persist for weeks to months. Respiratory support, nutritional and fluid management, treatment of complications
  • Botulinum Toxoid Vaccine is an investigational agent for individuals at high risk and is not effective in post exposure prophylaxis.

Staphylococcal Enterotoxin B (SEB)

• Symptoms
  • 2-12 hours after exposure. Fever (for 2-5days), chills, headache, myalgia, nonproductive cough (up to 4weeks).
  • May have SOB, retrosternal chest pain, nausea, vomiting, diarrhea, conjunctival injection, hypotension, CXR usually normal, but can have atelectasis, pulmonary edema.
  • Incapacitation for up to 2 weeks is usual, but rarely can progress to sepsis/death.
• Diagnosis - clinical; nonspecific labs, elevated WBC, ESR.
• Differential Diagnosis  - influenza, adenovirus, mycoplasma.
• Action - Draw acute and convalescent sera, urine sample for public health lab.
• Decontamination - hypochlorite 0.5% or 10-15min soap/water.
• Treatment - supportive, respiratory support, fluid management.
• Ricin
• Derived from castor bean, inhibits protein synthesis which results in cell death.
• Symptoms - (in 4-8 hours) weakness, fever, cough, hypothermia.
  • Inhalation - severe respiratory symptoms from necrosis and edema, hypoxia with respiratory failure in 36 -72 hours.
  • Ingestion - Nausea, vomiting, diarrhea, GI hemorrhage, vascular collapse, death. May cause DIC, multiple organ failure
• Diagnosis - Lab nonspecific, Serum ELISA available.
• Differential Diagnosis - SEB, Q Fever, tularemia, plague, phosgene. Collect serum samples.
• Decontamination - hypochlorite 0.5% solution, and/or soap/water.
• Treatment - supportive, O2, hydration. If ingestion, gastric lavage, superactivated charcoal followed by cathartics.
• Trichothecene
• Mycotoxins, T2. Fungal toxin- stable to heat and UV. Inhibits protein and nucleic acid synthesis affecting rapidly proliferating tissues. If aerosolized, it appears as yellow droplets - "yellow rain" – which can adhere to and penetrate skin, be inhaled and swallowed.
• Symptoms - onset minutes-4 hours- skin pain, pruritis, redness, vesicles, epidermal slough, eye irritation, nose throat pain, sneezing, wheezing, cough, dyspnea, chest pain, hemoptysis, abdominal pain, vomiting, bloody diarrhea. Bone marrow suppression can lead to diffuse hemorrhage. If severe, prostration, ataxia, collapse, shock and death in hours to days.
• Diagnosis - urine, blood, tissue samples for liquid chromatography-mass spectrometry.
• Decontamination - remove and isolate clothing, irrigate eyes with saline; wash with soap/water.
• Treatment - symptomatic/ supportive. If ingested, superactivated charcoal. No antidote.