NACCT Platform Abstracts 2012 - The American Academy of Clinical ...

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Botulism outbreak in a state prison from "pruno"
Ben T Williams 1 , Sarah Schlein 1 , Martin Caravati 1 , Benjamin Hatten
1 University of Utah, Salt Lake City UT USA
Background: Outbreaks of botulism in the US are very rare. We report a large outbreak of botulinum poisoning in a prison
population after ingestion of homemade "wine". Methods: This is an observational case series identified by a sentinel case in an
ED. Data was obtained from bedside exams and medical record reviews. Results: The sentinel case arrived in the ED 52 hours
after ingestion of a homemade alcoholic beverage (pruno) complaining of diplopia, dysarthria, fatigue, and dysphagia. At least
11 more prisoners subsequently admitted to consuming pruno. Eight patients consumed the first batch of pruno, which
contained a rotten potato and four patients consumed the second batch, which did not contain a potato. Two of the 4 patients
from the second batch of pruno were evaluated in the ED while the other 2 patients were evaluated by a neurologist via
telemedicine. None of these prisoners were admitted to the hospital but were observed in the prison infirmary. For the 8
patients who consumed the first batch of pruno, the mean onset of symptoms after ingestion was 75.5 hours. Initial symptoms
included: dysphagia (5pts), diplopia (4 pts), dysarthria (3pts) and general weakness (3pts). All 8 of these patients were
admitted to the ICU for monitoring and received antitoxin an average of 96 hrs after exposure. Seven of these 8 patients had
positive stool samples for botulinum toxin. Three patients developed respiratory failure and were intubated. The 5 patients who
did not require intubation had a mean Negative Inspiratory Force (NIF) of -58 cm H2O (range, -50 to -60) and a FVC of
4.36L range, 3.25 – 4.7). The 3 patients who required intubation had an average NIF of -35 cm H2O (range, -15 to -60) and
FVC of 3L (range, 0.9 t 4.7). All 8 patients had an EMG, which was abnormal in 1 of 5 non-intubated patients and in 2 of 3
intubated patients. Seven of 8 hospitalized patients had persistent symptoms 2 months post-ingestion. The 3 intubated patients
had a slower recovery with 2 requiring tracheostomy and PEG tube placement. These 2 patients required prolonged inpatient
stay in the rehabilitation unit and developed other complications associated with the exposure. They had removal of
tracheostomy and PEG at 51 and 90 days post-ingestion. Discussion: Ingestion of "pruno" at a state prison resulted in one of
the largest isolated outbreaks of botulism in the US within the last 10 years.