Journal of Neurology

, Volume 256, Issue 5, pp 803–809 | Cite as

Quantitative autonomic testing in the management of botulism

  • Raffi Topakian
  • Christoph Heibl
  • Karl Stieglbauer
  • Bettina Dreer
  • Markus Nagl
  • Peter Knoflach
  • Franz Thaddäus Aichner
Original Communication

Abstract

Even with mild neurological signs, patients with botulism frequently complain of autonomic symptoms. This study aimed at the evaluation of sudomotor and cardiovascular reflex functions by quantitative autonomic testing (QAT), which may identify patients with autonomic involvement but otherwise benign clinical presentation. Five patients with food-borne botulism were subjected to a structured questionnaire on autonomic symptoms, cardiac and neurological examination, and QAT after a median of 2 weeks (baseline) and 12 weeks (follow-up) post intoxication. For calculation of haemodynamic and cardiovascular autonomic parameters, we used the Task Force® Monitor (Version 2.1, CNSystems, Graz, Austria). Cardiovagal function was assessed by Ewing’s test battery. Autonomic complaints were more pronounced than neurological symptoms. Baseline tests revealed widely abnormal sudomotor function and marked impairment of heart rate variation and blood pressure response to standing. Prominent features of cardiovascular failure were high resting heart rate, supine hypertension, orthostatic hypotension, and impaired baroreflex function. Three patients reported inability to keep up with their routine amount of physical work. Based on the baseline QAT results, these three patients were instructed to engage in physical activity but avoid physical strain until there was considerable improvement. On follow-up, fatigue was the most frequent residual complaint, sympathetic skin responses were present, and cardiovascular QAT results were significantly improved and did not differ from those of ten control subjects. QAT identified autonomic involvement in botulism patients with otherwise benign neurological presentation. Comprehensive evaluation of autonomic failure may provide useful information for the management of botulism.

Keywords

Botulism Autonomic nervous system Autonomic failure Baroreflex function 

Notes

Conflict of interest statement

The authors report no conflicts of interest.

References

  1. 1.
    Ashley EA, Kardos A, Jack ES, Habenbacher W, Wheeler M, Kim YM, Froning J, Myers J, Whyte G, Froelicher V, Douglas P (2006) Angiotensin-converting enzyme genotype predicts cardiac and autonomic responses to prolonged exercise. J Am Coll Cardiol 48:523–531PubMedCrossRefGoogle Scholar
  2. 2.
    Chen JT, Chen CC, Lin KP, Wang SJ, Wu ZA, Liao KK (1999) Botulism: heart rate variation, sympathetic skin responses, and plasma norepinephrine. Can J Neurol Sci 26:123–126PubMedGoogle Scholar
  3. 3.
    Cherington M (1988) Clinical spectrum of botulism. Muscle Nerve 21:701–710CrossRefGoogle Scholar
  4. 4.
    Consensus Committee of the American Autonomic Society, the American Academy of Neurology (1996) Consensus statement on the definition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy. Neurology 46:1470Google Scholar
  5. 5.
    Dutsch M, Hilz MJ, Devinsky O (2006) Impaired baroreflex function in temporal lobe epilepsy. J Neurol 253:1300–1308PubMedCrossRefGoogle Scholar
  6. 6.
    Ewing DJ (1993) Noninvasive evaluation of heart rate: the time domain. In: Low PA (ed) Clinical autonomic disorders. Little Brown, Boston, pp 297–314Google Scholar
  7. 7.
    Gottlieb SL, Kretsinger K, Tarkhashvili N, Chakvetadze N, Chokheli M, Chubinidze M, Michael Hoekstra R, Jhorjholiani E, Mirtskhulava M, Moistsrapishvili M, Sikharulidze M, Zardiashvili T, Imnadze P, Sobel J (2007) Long-term outcomes of 217 botulism cases in the Republic of Georgia. Clin Infect Dis 45:174–180PubMedCrossRefGoogle Scholar
  8. 8.
    Gratze G, Fortin J, Holler A, Grasenick K, Pfurtscheller G, Wach P, Schönegger J, Kotanko P, Skrabal F (1998) A software package for non-invasive, real-time beat-to-beat monitoring of total peripheral resistance and for assessment of autonomic function. Comput Biol Med 28:121–142PubMedCrossRefGoogle Scholar
  9. 9.
    Ketch T, Biaggioni I, Robertson RM, Robertson D (2002) Four faces of baroreflex failure. Hypertensive crisis, volatile hypertension, orthostatic tachycardia, and malignant vagotonia. Circulation 105:2518–2523PubMedCrossRefGoogle Scholar
  10. 10.
    La Rovere MT, Bigger JT Jr, Marcus FI, Mortara A, Schwartz PJ (1998) Baroreflex sensitivity and heart-rate variability in prediction of total cardiac mortality after myocardial infarction: ATRAMI (autonomic tone and reflexes after myocardial infarction) investigators. Lancet 351:478–484PubMedCrossRefGoogle Scholar
  11. 11.
    Lecour H, Ramos H, Almeida B, Barbosa R (1988) Food-borne botulism. A review of 13 outbreaks. Arch Intern Med 148:578–580PubMedCrossRefGoogle Scholar
  12. 12.
    Merz B, Bigalke H, Stoll G, Naumann M (2003) Botulism type B presenting as pure autonomic dysfunction. Clin Auton Res 13:337–338PubMedCrossRefGoogle Scholar
  13. 13.
    Meusburger S, Reichert S, Heibl S, Nagl M, Karner F, Schachinger I, Allerberger F (2006) Outbreak of foodborne botulism linked to barbecue, Austria, 2006. Euro Surveill 11:E0612144Google Scholar
  14. 14.
    Neal KR, Dunbar EM (1990) Improvement in bulbar weakness with guanoxan in type B botulism. Lancet 335:1286–1287PubMedCrossRefGoogle Scholar
  15. 15.
    Nevas M, Lindstrom M, Virtanen A, Hielm S, Kuusi M, Arnon SS, Vuori E, Korkeala H (2005) Infant botulism acquired from household dust presenting as sudden infant death syndrome. J Clin Microbiol 43:511–513PubMedCrossRefGoogle Scholar
  16. 16.
    Robbe HW, Mulder LJ, Ruddel H, Langewitz WA, Veldman JB, Mulder G (1987) Assessment of baroreceptor reflex sensitivity by means of spectral analysis. Hypertension 10:538–543PubMedGoogle Scholar
  17. 17.
    Ryan DW, Cherington M (1971) Human type A botulism. JAMA 216:513–514PubMedCrossRefGoogle Scholar
  18. 18.
    Suarez GA, Opfer-Gehrking TL, Offord KP, Atkinson EJ, O’Brien PC, Low PA (1999) The autonomic symptom profile: a new instrument to assess autonomic symptoms. Neurology 52:523–528PubMedGoogle Scholar
  19. 19.
    Task Force of the European Society of Cardiology, the North American Society of Pacing, Electrophysiology (1996) Heart rate variability. Standards of measurement, physiological interpretation, and clinical use. Eur Heart J 17:354–381Google Scholar
  20. 20.
    Vita G, Girlanda P, Puglisi RM, Marabello L, Messina C (1987) Cardiovascular-reflex testing and single-fiber electromyography in botulism. A longitudinal study. Arch Neurol 44:202–206PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2009

Authors and Affiliations

  • Raffi Topakian
    • 1
  • Christoph Heibl
    • 2
  • Karl Stieglbauer
    • 1
  • Bettina Dreer
    • 2
  • Markus Nagl
    • 3
  • Peter Knoflach
    • 2
  • Franz Thaddäus Aichner
    • 1
  1. 1.Department of NeurologyAcademic Teaching Hospital Wagner-JaureggLinzAustria
  2. 2.Department of Internal Medicine IKlinikum Kreuzschwestern WelsWelsAustria
  3. 3.Division of Hygiene and Medical Microbiology, Department of Hygiene, Microbiology, and Social MedicineInnsbruck Medical UniversityInnsbruckAustria

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