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Case Of Diarrhea / vomiting

CASE No. 5

              A 12 year child presented to emergency of Hospital as a result of acute watery diarrhea. On examination he was faint and his mother told doctor that he had a burger from McDonalds last night. He has been vomiting since last night.
How should this patient be handled when the organism found was Botulinium?
Treat this patient accordingly?
Give Rationale of Use of Drugs.

INTRODUCTION:
                                    Acute watery diarrhea caused by Clostridium botulinum is an infective diarrhea. Clostridium botulinum is a Gram +ve bacteria that produces Neurotoxin generically called botulinum toxin. Food-borne botulism is caused by eating foods that contain the botulinum neurotoxin

1. INITIAL MANAGEMENT OF BOTULISM:
Empirical therapy of watery Diarrhea includes Ciprofloxacin as drug of choice or erythromycin 500 mg 4 times daily.
ORS can be used to treat diarrhea regardless of the patient’s age, causative pathogen, or initial sodium values.
In the case history the patient is diagnosed as being infected from Botulinium toxins secreted by Clostridium botulinum. So the patient is first given the symptomatic treatment and then after confirming the presence of causative agent, definitive therapy is suggested.
ORAL FLUIDS AND ELECTROLYTE REPLACEMTN is of prime importance. Special oral rehydration solutions are given
ANTIDIARRHOEAL DRUGS such as Codeine phosphate 30 mg four times daily, or loperamide 2 mg t.i.d. can be given for short term treatment but it can impair the clearance of causative pathogen

TREATMENT:
As the initial therapy is started and confirmation of Botulinium Toxin is made in faces or contaminated food, the child is keenly observed under strict supervision that:
No symptoms of toxins appear such as cranial nerve weakness, progressive symmetrical paralysis leading to respiratory failure.
A trivalent Botulism antitoxin is available for post exposure prophylaxis of Botulism. It is effective against Clostridium botulinum toxins types A,B, & E.
IV REHYDRATION FLUIDS Ringer Lactate and Dacca Solution
If the patient can take oral fluids than it should be preferred.
RATIONALE OF USE OF DRUGS:
Following drugs are used in the empirical and definitive therapy of Botulism.
Ciprofloxacin
IV infusion over 30 – 60 minutes. 10 mg/kg t.i.d max. 1.2g daily. The infusion contains 15.4 mmol/100 ml in bottle so Na overload should be monitored.
Erythromycin
Continuous infusion at 50mg/kg daily. Dissolve initially in water for injection (I g in 20ml) then dilute to a concentration of 1mg/ml, for continuous infusion
Botulism antitoxin:
Patient should be tested for hypersensitivity reactions and past antitoxin administration.

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