- Email: [email protected]
The first case of botulism type F in Portugal
Abstracts / Toxicon 123 (2016) S2eS90
the same physician. Treatment was discontinued in 25 patients due to “lack of efficacy” (n¼8), “spontaneous improvement of symptoms” (n¼8), and “other reasons” (n¼9). Conclusions: Most patients were satisfied with flexible injection intervals and the possibility of receiving injections immediately when deterioration of symptoms occurred. The main reason for patient satisfaction in BoNT patients no longer treated in our clinic was being treated by the same physician. Editorial support funded by Merz Pharmaceuticals. Keywords: Botulinum toxin; Flexible injection intervals; Satisfaction; Survey 144. FIRST GLANCE INTO SINGLE-CELL-LEVEL PRODUCTION SUGGESTS HETEROGENEITY IN PRODUCTION IN CLOSTRIDIUM BOTULINUM CULTURES
NEUROTOXIN NEUROTOXIN
Anna Mertaoja a, Gerald Mascher a, Adriano O. Henriques b, Hannu € m a, *. Korkeala a, Miia Lindstro a Department of Food Hygiene and Environmental Health, Faculty of Veterinary Medicine, University of Helsinki, Helsinki, Finland; b Instituto de gica, Universidade Nova de Lisboa, Lisbon, Tecnologia Química e Biolo Portugal * Corresponding author: Department of Food Hygiene and Environmental Health, Faculty of Veterinary Medicine, P.O. Box 66, 00014, University of Helsinki, Finland. E-mail address:miia.lindstrom@helsinki.fi.
The high potency of botulinum neurotoxin (BoNT) and the expected fitness cost of production of this large protein complex imply that BoNT synthesis in Clostridium botulinum cultures is efficiently controlled. It is unclear what kind of a competitive advantage BoNT production provides for C. botulinum in its natural habitat and whether all cells in a culture express this costly trait. We established a fluorescent reporter system for single-cell gene expression analysis in C. botulinum to shed light on the commitment of C. botulinum cells to BoNT production and sporulation. A plasmid containing the fluorescent reporter SNAP-tag (based on the DNA repair protein O6alkylguanine-DNA alkyltransferase) under the control of the native toxin gene promoter (pbot) was introduced into C. botulinum Beluga wild type and into a sporulation null mutant. The cultures were grown at conditions supporting vegetative growth or sporulation, and under stress. Collected cells were labeled with a fluorescent cell-permeable substrate and imaged by fluorescence microscopy to detect and quantify the SNAP-tag in fixed cells, reporting pbot activity at a given time at the single-cell level. The percentage of SNAP-producing (pbot+) cells and the average fluorescent signal intensity of each individual cell were recorded, and the cultures were tested for BoNT production. The average fluorescent signal intensity of individual log-phase pbot+ cells, and the percentage of pbot+ cells, correlated with intracellular BoNT concentrations, demonstrating that our system reliably reported on BoNT expression. Our results suggest that C. botulinum cultures divide the labor of BoNT production between cells according to environmental cues. Our future research aims to clarify the roles and tasks of individual cells in C. botulinum cultures and to identify the mechanisms used to coordinate the work distribution. The results are expected to provide novel insights into the role of BoNT production in the life of C. botulinum and into the natural cellular machineries controlling toxin production. Keywords: BoNT production; Clostridium botulinum; Fluorescence microscopy; Gene regulation 145. RATIONAL MODIFICATION OF BOTULINUM NEUROTOXIN BY DIRECTED SCANNING MUTAGENESIS Sai Man Liu a, Gavin Hackett a, Elena Fonfria a, Shilpa Palan a, Sylvie Cornet b, Agnieszka Lewandowska a, Sarah Donald a, Dave Burgin a, Joshua Sopp a, Fraser Hornby a, Sandra Marlin a, Cindy Perier b, Dina Anderson a, *. a Ipsen Bioinnovation, Abingdon, UK; b Ipsen Innovation, Les Ulis, France
S55
* Corresponding author: Ipsen Bioinnovation, 102 Park Drive, Abingdon, Oxfordshire OX14 4RY, UK. E-mail address:[email protected].
Introduction and objectives: Botulinum neurotoxins (BoNTs) have found wide application as therapeutic agents for the treatment of a range of neuromuscular disorders due to their potency and specificity for neuronal cells (Chen 2013). They comprise 3 structurally and functionally distinct domains (a light chain [LC], N-terminal domain of the heavy chain [HN], and C-terminal domain of the heavy chain [HC]), which may be modified to enhance/alter their activity; however, the challenge is to identify residues and regions in the molecule suitable for modification without disrupting BoNT function. To achieve this, we have used selective lysine (due to its suitability for chemical and biologic coupling) scanning mutagenesis and characterized the resulting molecules in in vitro and in vivo assays to identify suitable positions for future modification. Methods: Analysis of the BoNT structure identified suitable, solventaccessible residues. Individual and/or multiple mutations were introduced into all domains of BoNT/A and the LC of BoNT/E (LC/E). Constructs were expressed and purified from Escherichia coli. Potency was assessed by BoTest, a cellular SNAP-25 cleavage assay, an ex vivo mouse phrenic nerve/ hemidiaphragm preparation (mPNHD), and the rat Digit Abduction Score model. Results: Residues in LC/E and the HN and HC domains of BoNT/A were identified that did not negatively affect potency compared with the references, retaining both in vitro and in vivo activity. Interestingly, there were instances in all domains where modifications affected potency despite structural considerations. Conclusions: In the absence of a complete understanding of the structurefunction relationship of BoNT domains, we used rational scanning mutagenesis in regions of interest to identify potential sites for modification. We demonstrated the feasibility of the approach by assessing their impact in a suite of assays to evaluate the modified molecules. The ability to identify suitable sites for mutation will enable future modification of BoNT molecules with greater confidence. Funding: Ipsen S.A. Keywords: BoNT; Botulinum; Modification; Potency; Scanning; Structure Reference Chen JJ, Dashtipour K. Abo-, inco-, ona-, and rima-botulinum toxins in clinical therapy: a primer. Pharmacotherapy. 2013;33:304-318. 146. PARIETAL HAND PSEUDODYSTONIA TREATED WITH ULTRASOUNDGUIDED BOTULINUM TOXIN INJECTIONS Patrícia Pita Lobo*, Cristina Costa. Department of Neurology, Hospital Prof Dr Fernando Fonseca, Amadora, Portugal * Corresponding author: Department of Neurology, Hospital Prof Dr Fernando Fonseca, IC-19, Amadora, 2720-286, Portugal. E-mail address:anapa.pitalobo@gmail. com.
Introduction and objectives: Symptomatic focal dystonia is most commonly secondary to lesions in the basal ganglia. Some reports have documented the occurrence of focal dystonic postures and chorea in parietal cortical lesions (pseudodystonia). There are no approved treatments for these disabling dystonic postures. We report a case of a patient with parietal hand pseudodystonia treated with botulinum toxin (BT). Methods: A 74-year-old woman with a history of right parietal stroke presented initially with a left sensorimotor deficit. Despite improvement of limb paresis with physiotherapy, the patient complained of abnormal postures and a nonfunctional left hand, which hindered her activities of daily living (ADLs). On observation, there was mild right hand somatosensory and proprioceptive impairment, slight astereognosis, minor left upper limb (UL) paresis (grade 4 + /5 on the Medical Research Council scale), slight spasticity, and moderate pseudodystonia of the UL. Ultrasound (US)-guided BT injections were proposed to ameliorate the pseudodystonia. Botox (Allergan) was administered to forearm muscles on 4 sessions at 3-month intervals. Doses and pattern of injected muscles (agonist and antagonist) were adjusted as needed in subsequent treatments. Total dose on last treatment was 90 U.
S56
Abstracts / Toxicon 123 (2016) S2eS90
Results: The patient was assessed at baseline (P0; pretreatment) and 6 weeks after the fourth treatment (P4) using Goal Attainment scaling (GAS) with a change score of 25.4. She reported significant improvements in performing ADLs, with gain of autonomy. There was a reduction in frequency and severity of dystonic postures from P0 to P4. Patient's follow-up showed maintenance of benefit at 9 months after the last treatment. Conclusions: We report a nonfunctional pseudodystonic hand, which improved after treatment with US-guided BT treatment, illustrating the potential usefulness of BT in the treatment of incapacitating dystonic postures secondary to central somatosensory deficits originating outside the basal ganglia. Keywords: Botulinum toxin; Dystonia; Pseudodystonia; Ultrasound guided 147. THE FIRST CASE OF BOTULISM TYPE F IN PORTUGAL Teresa Teixeira Lopes a, Margarida Saraiva a, *, Isabel Bastos Moura a, Rosa Andre Milit~ ao c, Adelaide Coelho d, Orta Santos Ribeiro b, d a a ~ Gomes , Conceiçao Costa Bonito , Claudia Pena , Isabel Campos nio Cunha a, Isabel Sousa a, Maria Manuel Toscano a, Elsa Soares d, Anto nia Calhau a. Tavares d, Maria Anto a Microbiology Laboratory, Reference Unit, Food and Nutrition Department, National Health Institute Doutor Ricardo Jorge, IP, Oporto, Portugal; b Intensive Care Service, St. Bernard Hospital, Centre Hospitalier de Setúbal, EPE, Setúbal, Portugal; c Neurology Service, St. Bernard Hospital, Centre Hospitalier de Setúbal, EPE, Setúbal, Portugal; d Department of Public Health, Regional Health Administration of Lisbon and Tagus Valley, IP, Lisbon, Portugal
reported cases of type F botulism, no source of exposure was identified in this patient.1 Keywords: Botulinum toxin type F; Clostridium botulinum; Neurotoxin; Portugal References 1. European Centre for Disease Prevention and Control (ECDC). Technical Report. Scientific Advice on Type F Botulism. Stockholm, Sweden: ECDC; 2013. http://www.ecdc.europa.eu/en/publications/Publications/botulismscientific-advice-type-F-botulism.pdf. 2. Centers for Disease Control and Prevention. Clostridium botulinum Monovalent and Polyvalent Antitoxins. Atlanta, Georgia: Centers for Disease Control and Prevention, US Dept of Health and Human Services;1987. 3. Austin JW, Sanders G. The Detection of Clostridium botulinum and Its toxins in Suspect Foods and Clinical Specimens. Compendium of Analytical Methods. vol. 2. 2009:1-9. 4. De Medici D, Anniballi F, Wyatt GM, et al. Multiplex PCR for detection of botulinum neurotoxin-producing clostridia in clinical, food, and environmental samples. Appl Environ Microbiol. 2009; 75(20):6457-6461. 148. TRANSORAL ADMINISTRATION OF INCOBOTULINUMTOXINA FOR THE MANAGEMENT OF LARYNGEAL DYSTONIA Miguel Sebastia n Cortes b, Paúl Ricardo pez del Val a, *, Jose Javier Lo a b Vinueza Buitron , Yolanda Lois Ortega , Hector Valles Varea b, Elena pez García a, Elena Bellosta Diago b, Sonia Santos Lasaosa a. Lo a Neurology Service, Movement Disorders Unit, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain; b Otolaryngology Service, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
* Corresponding author: National Health Institute Doutor Ricardo Jorge, Rua Alexandre Herculano, 321, 4000-055, IP, Porto, Portugal. E-mail address:margarida. [email protected].
* Corresponding author: Neurology Service, Movement Disorders Unit, Hospital Clínico Universitario Lozano Blesa, Avenida San Juan Bosco, 50009 Zaragoza, Spain. E-mail address:[email protected].
Botulinum toxin type F (BoNT/F) from the stool of a patient with symptoms of botulism was detected in Portugal in July 2016. A strain that exhibited the phenotypic characteristics of Clostridium botulinum serotype F was also isolated. All known human cases have been caused by toxin types A, B, E and, more rarely, type F. In the vast majority of cases, the toxin Feproducing organism was C botulinum and sometimes C baratii.1 Ingestion of contaminated food or, more rarely, infection of an exposed wound or growth in an immunologically immature intestinal tract (infant botulism) or adult intestinal colonization can produce the clinical syndrome of botulism.1 A 53-year-old man was admitted to the Emergency Department of St. Bernard Hospital reporting symptoms of botulism, including blurred vision, diplopia, ptosis, dysarthria, dysphagia, dry mouth, and bilateral nonreactive mydriasis. He reported nausea, abdominal distress, and vomiting after dinner on the previous day. The patient was hospitalized syndrome. with a possible diagnosis of botulism vs atypical Guillain-Barre He sought treatment in the intensive care unit with urinary retention, flaccid paraparesis, progressive respiratory distress, and needing respiratory assistance. A serum sample and a stool sample resulting from a microenema were collected and sent to the laboratory. Epidemiological and environmental investigations were carried out by local public health teams, supported by the regional health authority. Interviews with family members were conducted to identify suspected foods. A selection of canned foods of the same brand as that ingested by the patient was sent to the laboratory. The serum and stool samples were tested with the standard mouse bioassay2, and the stool sample was also tested for the presence of BoNTproducing Clostridia (with multiplex-PCR and culture).3,4 BoNT/F was detected in the stools. In the serum sample the assay was not conclusive. The food samples were analyzed for the presence of toxin (mouse bioassay)2 and for BoNT-producing Clostridia (with multiplex-PCR and culture).3,4 BoNT and BoNT-producing Clostridia were not detected. Some of the few cases of BoNT/F in adults reported were due to adult colonization and others to food-borne botulism.1 As in the majority of
Introduction and objectives: Laryngeal dystonia is a movement disorder of the muscles within the larynx, which most commonly manifests as spasmodic dysphonia (SD). The use of botulinum toxin (BTX) in the treatment of SD has a major clinical impact with a marked improvement of symptoms. One of the injection routes of administration of BTX is the transoral approach. The objective of this study is to describe our experience using the transoral technique for administration of incobotulinumtoxinA in patients with SD. Methods: We have treated 15 patients (11 female; 4 male) diagnosed of adductor or abductor SD during 134 therapeutic administrations of incobotulinumtoxinA via the transoral route with direct injection into the vocal cord. A dose of 5 international units (IU) per vocal cord was administered. Ten patients (66.67%) had adductor SD, 3 (20%) had abductor SD; in 1 patient (6.67%), the laryngeal disorder was integrated in a process of generalized dystonia, and in 1 patient (6.67%), SD was accompanied by cervical dystonia. The procedure was carried out under local anesthesia with aerosolized lidocaine diluted according to the anatomical area, and the injection was performed using a Chiba needle with the help of a flexible fibroendoscope. In order to assess the degree of therapeutic response, a patient-reported self-assessment scale (1: no improvement; 5: very much improved) was developed. The site of injection was the same regardless of the type of laryngeal dystonia. Results: Patients received a mean dose of 5 IU per vocal cord (minimum 2.5 IU and maximum 7.5 IU). Average duration of the therapeutic beneficial effect was 5.3 months (95% CI: 4.9 -5.7 months). In our group of patients, 29.3% rated the improvement as marked-moderate and 64.7% rated it as very much improved. Patients reported adverse effects in 11.9% of treatment sessions, most commonly transient and mild dysphagia, dysphonia, and choking. Conclusions: In our experience, the transoral injection technique of botulinum toxin for the treatment of SD (both adductor and abductor forms) is an effective, easy to perform, and well-tolerated treatment provided good anesthesia and relaxation of treated patients is achieved. Keywords: IncobotulinumtoxinA; Laryngeal dystonia
the same physician. Treatment was discontinued in 25 patients due to “lack of efficacy” (n¼8), “spontaneous improvement of symptoms” (n¼8), and “other reasons” (n¼9). Conclusions: Most patients were satisfied with flexible injection intervals and the possibility of receiving injections immediately when deterioration of symptoms occurred. The main reason for patient satisfaction in BoNT patients no longer treated in our clinic was being treated by the same physician. Editorial support funded by Merz Pharmaceuticals. Keywords: Botulinum toxin; Flexible injection intervals; Satisfaction; Survey 144. FIRST GLANCE INTO SINGLE-CELL-LEVEL PRODUCTION SUGGESTS HETEROGENEITY IN PRODUCTION IN CLOSTRIDIUM BOTULINUM CULTURES
NEUROTOXIN NEUROTOXIN
Anna Mertaoja a, Gerald Mascher a, Adriano O. Henriques b, Hannu € m a, *. Korkeala a, Miia Lindstro a Department of Food Hygiene and Environmental Health, Faculty of Veterinary Medicine, University of Helsinki, Helsinki, Finland; b Instituto de gica, Universidade Nova de Lisboa, Lisbon, Tecnologia Química e Biolo Portugal * Corresponding author: Department of Food Hygiene and Environmental Health, Faculty of Veterinary Medicine, P.O. Box 66, 00014, University of Helsinki, Finland. E-mail address:miia.lindstrom@helsinki.fi.
The high potency of botulinum neurotoxin (BoNT) and the expected fitness cost of production of this large protein complex imply that BoNT synthesis in Clostridium botulinum cultures is efficiently controlled. It is unclear what kind of a competitive advantage BoNT production provides for C. botulinum in its natural habitat and whether all cells in a culture express this costly trait. We established a fluorescent reporter system for single-cell gene expression analysis in C. botulinum to shed light on the commitment of C. botulinum cells to BoNT production and sporulation. A plasmid containing the fluorescent reporter SNAP-tag (based on the DNA repair protein O6alkylguanine-DNA alkyltransferase) under the control of the native toxin gene promoter (pbot) was introduced into C. botulinum Beluga wild type and into a sporulation null mutant. The cultures were grown at conditions supporting vegetative growth or sporulation, and under stress. Collected cells were labeled with a fluorescent cell-permeable substrate and imaged by fluorescence microscopy to detect and quantify the SNAP-tag in fixed cells, reporting pbot activity at a given time at the single-cell level. The percentage of SNAP-producing (pbot+) cells and the average fluorescent signal intensity of each individual cell were recorded, and the cultures were tested for BoNT production. The average fluorescent signal intensity of individual log-phase pbot+ cells, and the percentage of pbot+ cells, correlated with intracellular BoNT concentrations, demonstrating that our system reliably reported on BoNT expression. Our results suggest that C. botulinum cultures divide the labor of BoNT production between cells according to environmental cues. Our future research aims to clarify the roles and tasks of individual cells in C. botulinum cultures and to identify the mechanisms used to coordinate the work distribution. The results are expected to provide novel insights into the role of BoNT production in the life of C. botulinum and into the natural cellular machineries controlling toxin production. Keywords: BoNT production; Clostridium botulinum; Fluorescence microscopy; Gene regulation 145. RATIONAL MODIFICATION OF BOTULINUM NEUROTOXIN BY DIRECTED SCANNING MUTAGENESIS Sai Man Liu a, Gavin Hackett a, Elena Fonfria a, Shilpa Palan a, Sylvie Cornet b, Agnieszka Lewandowska a, Sarah Donald a, Dave Burgin a, Joshua Sopp a, Fraser Hornby a, Sandra Marlin a, Cindy Perier b, Dina Anderson a, *. a Ipsen Bioinnovation, Abingdon, UK; b Ipsen Innovation, Les Ulis, France
S55
* Corresponding author: Ipsen Bioinnovation, 102 Park Drive, Abingdon, Oxfordshire OX14 4RY, UK. E-mail address:[email protected].
Introduction and objectives: Botulinum neurotoxins (BoNTs) have found wide application as therapeutic agents for the treatment of a range of neuromuscular disorders due to their potency and specificity for neuronal cells (Chen 2013). They comprise 3 structurally and functionally distinct domains (a light chain [LC], N-terminal domain of the heavy chain [HN], and C-terminal domain of the heavy chain [HC]), which may be modified to enhance/alter their activity; however, the challenge is to identify residues and regions in the molecule suitable for modification without disrupting BoNT function. To achieve this, we have used selective lysine (due to its suitability for chemical and biologic coupling) scanning mutagenesis and characterized the resulting molecules in in vitro and in vivo assays to identify suitable positions for future modification. Methods: Analysis of the BoNT structure identified suitable, solventaccessible residues. Individual and/or multiple mutations were introduced into all domains of BoNT/A and the LC of BoNT/E (LC/E). Constructs were expressed and purified from Escherichia coli. Potency was assessed by BoTest, a cellular SNAP-25 cleavage assay, an ex vivo mouse phrenic nerve/ hemidiaphragm preparation (mPNHD), and the rat Digit Abduction Score model. Results: Residues in LC/E and the HN and HC domains of BoNT/A were identified that did not negatively affect potency compared with the references, retaining both in vitro and in vivo activity. Interestingly, there were instances in all domains where modifications affected potency despite structural considerations. Conclusions: In the absence of a complete understanding of the structurefunction relationship of BoNT domains, we used rational scanning mutagenesis in regions of interest to identify potential sites for modification. We demonstrated the feasibility of the approach by assessing their impact in a suite of assays to evaluate the modified molecules. The ability to identify suitable sites for mutation will enable future modification of BoNT molecules with greater confidence. Funding: Ipsen S.A. Keywords: BoNT; Botulinum; Modification; Potency; Scanning; Structure Reference Chen JJ, Dashtipour K. Abo-, inco-, ona-, and rima-botulinum toxins in clinical therapy: a primer. Pharmacotherapy. 2013;33:304-318. 146. PARIETAL HAND PSEUDODYSTONIA TREATED WITH ULTRASOUNDGUIDED BOTULINUM TOXIN INJECTIONS Patrícia Pita Lobo*, Cristina Costa. Department of Neurology, Hospital Prof Dr Fernando Fonseca, Amadora, Portugal * Corresponding author: Department of Neurology, Hospital Prof Dr Fernando Fonseca, IC-19, Amadora, 2720-286, Portugal. E-mail address:anapa.pitalobo@gmail. com.
Introduction and objectives: Symptomatic focal dystonia is most commonly secondary to lesions in the basal ganglia. Some reports have documented the occurrence of focal dystonic postures and chorea in parietal cortical lesions (pseudodystonia). There are no approved treatments for these disabling dystonic postures. We report a case of a patient with parietal hand pseudodystonia treated with botulinum toxin (BT). Methods: A 74-year-old woman with a history of right parietal stroke presented initially with a left sensorimotor deficit. Despite improvement of limb paresis with physiotherapy, the patient complained of abnormal postures and a nonfunctional left hand, which hindered her activities of daily living (ADLs). On observation, there was mild right hand somatosensory and proprioceptive impairment, slight astereognosis, minor left upper limb (UL) paresis (grade 4 + /5 on the Medical Research Council scale), slight spasticity, and moderate pseudodystonia of the UL. Ultrasound (US)-guided BT injections were proposed to ameliorate the pseudodystonia. Botox (Allergan) was administered to forearm muscles on 4 sessions at 3-month intervals. Doses and pattern of injected muscles (agonist and antagonist) were adjusted as needed in subsequent treatments. Total dose on last treatment was 90 U.
S56
Abstracts / Toxicon 123 (2016) S2eS90
Results: The patient was assessed at baseline (P0; pretreatment) and 6 weeks after the fourth treatment (P4) using Goal Attainment scaling (GAS) with a change score of 25.4. She reported significant improvements in performing ADLs, with gain of autonomy. There was a reduction in frequency and severity of dystonic postures from P0 to P4. Patient's follow-up showed maintenance of benefit at 9 months after the last treatment. Conclusions: We report a nonfunctional pseudodystonic hand, which improved after treatment with US-guided BT treatment, illustrating the potential usefulness of BT in the treatment of incapacitating dystonic postures secondary to central somatosensory deficits originating outside the basal ganglia. Keywords: Botulinum toxin; Dystonia; Pseudodystonia; Ultrasound guided 147. THE FIRST CASE OF BOTULISM TYPE F IN PORTUGAL Teresa Teixeira Lopes a, Margarida Saraiva a, *, Isabel Bastos Moura a, Rosa Andre Milit~ ao c, Adelaide Coelho d, Orta Santos Ribeiro b, d a a ~ Gomes , Conceiçao Costa Bonito , Claudia Pena , Isabel Campos nio Cunha a, Isabel Sousa a, Maria Manuel Toscano a, Elsa Soares d, Anto nia Calhau a. Tavares d, Maria Anto a Microbiology Laboratory, Reference Unit, Food and Nutrition Department, National Health Institute Doutor Ricardo Jorge, IP, Oporto, Portugal; b Intensive Care Service, St. Bernard Hospital, Centre Hospitalier de Setúbal, EPE, Setúbal, Portugal; c Neurology Service, St. Bernard Hospital, Centre Hospitalier de Setúbal, EPE, Setúbal, Portugal; d Department of Public Health, Regional Health Administration of Lisbon and Tagus Valley, IP, Lisbon, Portugal
reported cases of type F botulism, no source of exposure was identified in this patient.1 Keywords: Botulinum toxin type F; Clostridium botulinum; Neurotoxin; Portugal References 1. European Centre for Disease Prevention and Control (ECDC). Technical Report. Scientific Advice on Type F Botulism. Stockholm, Sweden: ECDC; 2013. http://www.ecdc.europa.eu/en/publications/Publications/botulismscientific-advice-type-F-botulism.pdf. 2. Centers for Disease Control and Prevention. Clostridium botulinum Monovalent and Polyvalent Antitoxins. Atlanta, Georgia: Centers for Disease Control and Prevention, US Dept of Health and Human Services;1987. 3. Austin JW, Sanders G. The Detection of Clostridium botulinum and Its toxins in Suspect Foods and Clinical Specimens. Compendium of Analytical Methods. vol. 2. 2009:1-9. 4. De Medici D, Anniballi F, Wyatt GM, et al. Multiplex PCR for detection of botulinum neurotoxin-producing clostridia in clinical, food, and environmental samples. Appl Environ Microbiol. 2009; 75(20):6457-6461. 148. TRANSORAL ADMINISTRATION OF INCOBOTULINUMTOXINA FOR THE MANAGEMENT OF LARYNGEAL DYSTONIA Miguel Sebastia n Cortes b, Paúl Ricardo pez del Val a, *, Jose Javier Lo a b Vinueza Buitron , Yolanda Lois Ortega , Hector Valles Varea b, Elena pez García a, Elena Bellosta Diago b, Sonia Santos Lasaosa a. Lo a Neurology Service, Movement Disorders Unit, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain; b Otolaryngology Service, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
* Corresponding author: National Health Institute Doutor Ricardo Jorge, Rua Alexandre Herculano, 321, 4000-055, IP, Porto, Portugal. E-mail address:margarida. [email protected].
* Corresponding author: Neurology Service, Movement Disorders Unit, Hospital Clínico Universitario Lozano Blesa, Avenida San Juan Bosco, 50009 Zaragoza, Spain. E-mail address:[email protected].
Botulinum toxin type F (BoNT/F) from the stool of a patient with symptoms of botulism was detected in Portugal in July 2016. A strain that exhibited the phenotypic characteristics of Clostridium botulinum serotype F was also isolated. All known human cases have been caused by toxin types A, B, E and, more rarely, type F. In the vast majority of cases, the toxin Feproducing organism was C botulinum and sometimes C baratii.1 Ingestion of contaminated food or, more rarely, infection of an exposed wound or growth in an immunologically immature intestinal tract (infant botulism) or adult intestinal colonization can produce the clinical syndrome of botulism.1 A 53-year-old man was admitted to the Emergency Department of St. Bernard Hospital reporting symptoms of botulism, including blurred vision, diplopia, ptosis, dysarthria, dysphagia, dry mouth, and bilateral nonreactive mydriasis. He reported nausea, abdominal distress, and vomiting after dinner on the previous day. The patient was hospitalized syndrome. with a possible diagnosis of botulism vs atypical Guillain-Barre He sought treatment in the intensive care unit with urinary retention, flaccid paraparesis, progressive respiratory distress, and needing respiratory assistance. A serum sample and a stool sample resulting from a microenema were collected and sent to the laboratory. Epidemiological and environmental investigations were carried out by local public health teams, supported by the regional health authority. Interviews with family members were conducted to identify suspected foods. A selection of canned foods of the same brand as that ingested by the patient was sent to the laboratory. The serum and stool samples were tested with the standard mouse bioassay2, and the stool sample was also tested for the presence of BoNTproducing Clostridia (with multiplex-PCR and culture).3,4 BoNT/F was detected in the stools. In the serum sample the assay was not conclusive. The food samples were analyzed for the presence of toxin (mouse bioassay)2 and for BoNT-producing Clostridia (with multiplex-PCR and culture).3,4 BoNT and BoNT-producing Clostridia were not detected. Some of the few cases of BoNT/F in adults reported were due to adult colonization and others to food-borne botulism.1 As in the majority of
Introduction and objectives: Laryngeal dystonia is a movement disorder of the muscles within the larynx, which most commonly manifests as spasmodic dysphonia (SD). The use of botulinum toxin (BTX) in the treatment of SD has a major clinical impact with a marked improvement of symptoms. One of the injection routes of administration of BTX is the transoral approach. The objective of this study is to describe our experience using the transoral technique for administration of incobotulinumtoxinA in patients with SD. Methods: We have treated 15 patients (11 female; 4 male) diagnosed of adductor or abductor SD during 134 therapeutic administrations of incobotulinumtoxinA via the transoral route with direct injection into the vocal cord. A dose of 5 international units (IU) per vocal cord was administered. Ten patients (66.67%) had adductor SD, 3 (20%) had abductor SD; in 1 patient (6.67%), the laryngeal disorder was integrated in a process of generalized dystonia, and in 1 patient (6.67%), SD was accompanied by cervical dystonia. The procedure was carried out under local anesthesia with aerosolized lidocaine diluted according to the anatomical area, and the injection was performed using a Chiba needle with the help of a flexible fibroendoscope. In order to assess the degree of therapeutic response, a patient-reported self-assessment scale (1: no improvement; 5: very much improved) was developed. The site of injection was the same regardless of the type of laryngeal dystonia. Results: Patients received a mean dose of 5 IU per vocal cord (minimum 2.5 IU and maximum 7.5 IU). Average duration of the therapeutic beneficial effect was 5.3 months (95% CI: 4.9 -5.7 months). In our group of patients, 29.3% rated the improvement as marked-moderate and 64.7% rated it as very much improved. Patients reported adverse effects in 11.9% of treatment sessions, most commonly transient and mild dysphagia, dysphonia, and choking. Conclusions: In our experience, the transoral injection technique of botulinum toxin for the treatment of SD (both adductor and abductor forms) is an effective, easy to perform, and well-tolerated treatment provided good anesthesia and relaxation of treated patients is achieved. Keywords: IncobotulinumtoxinA; Laryngeal dystonia