> Date: Fri, 21 Jul 2006 16:00:52 -0400 (EDT)
> From: ProMED-mail <promed@promed.isid.harvard.edu>
> Subject: PRO/EDR> Botulism, smoked fish - Finland ex Canada
>
> BOTULISM, SMOKED FISH - FINLAND EX CANADA
> ***********************************
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>
> Date: Thu, 20 July 2006
> From: ProMED-mail <promed@promedmail.org>
> Source: Eurosurveillance [edited]
> <http://www.eurosurveillance.org/ew/2006/060720.asp#3>
>
>
> On 29 Jun 2006, a 65-year-old woman fell ill with vomiting and
> diarrhea in southern Finland. The next day she developed muscular
> weakness of her upper and lower limbs, and was admitted to hospital.
> She developed difficulty in breathing and required mechanical
> ventilation in an intensive care unit for a week.
>
> The patient is now recovering, but still has some difficulties in
> swallowing, and is not yet able to walk. The patient did not receive
> botulinum antitoxin, since the symptoms had already begun to resolve
> upon diagnosis. The patient's husband also had diarrhea on 29 Jun
> 2006 and later had some difficulties in swallowing, but no other
> neurological symptoms were observed. He was admitted to hospital for
> one night (1-2 Jul 2006) because of diarrhea.
>
> Serum samples from the female patient taken on 30 Jun and 1 Jul 2006
> were positive for botulinum neurotoxin by mouse bioassay, and the
> neutralization test suggested that the patient's illness was caused
> by botulinum toxin type E. Gastric fluid and serum samples taken on 4
> Jul 2006 did not yield neurotoxin or _Clostridium botulinum_. No
> specimens were available from the husband, as botulism was not
> diagnosed during his hospital stay, and he was not called back to
> hospital for specimens.
>
> An interview with the husband revealed that the couple had eaten
> smoked vacuum-packed whitefish on 28 Jun 2006. The wife had eaten
> most of the fish, and the husband ate only a small portion. The
> whitefish had been imported from Canada, but smoked and packed in
> Finland. There was no leftover fish for microbiological examination.
> Flush samples were taken from the fish's plastic packaging, but they
> were negative for _C. botulinum_ by PCR (1) and culture.
>
> The suspected fish product was recalled by the manufacturer, and
> production of the product was suspended. The national and local food
> control authorities inspected the production plant and the
> distribution center. The entire manufacturing process and storage
> temperatures throughout the cold chain, including the retail outlet,
> were investigated. The inspections did not reveal any factors that
> could have created an increased risk of botulinum neurotoxin
> production. Microbiological analysis of 10 vacuum-packed fish made
> from the same raw fish batch that was used to make the product eaten
> by the patient, and from fish from earlier and later batches, were
> all negative for _C. botulinum_.
>
> The investigators have therefore hypothesized that there may have
> been storage temperature abuse at a later stage, such as in the
> retail outlet or the home. After inspection of the facility and
> microbiological examination of fish samples, production of the
> product has started again.
>
> _C. botulinum_ type E is naturally highly prevalent in aquatic
> environments and fish (2,3), leading to a high risk of contamination.
> The hot-smoking processes are usually too low to eliminate botulinum
> spores (4). Growth and toxin production from spores in vacuum-packed
> smoked fish products with anaerobic atmosphere and limited
> preservative factors is likely during extended storage at
> temperatures above 3 degrees C. Therefore the most important factors
> controlling _C. botulinum_ growth and toxin production are efficient
> heat treatments, restricted shelf life and continuous storage below 3
> degrees C.
>
> Human botulism is a very rare disease; the most recent case to be
> reported in Finland before the one mentioned here occurred in 1999
> (5). A similar outbreak that affected 2 people in Germany in 1997 is
> described in the literature (1). However, it is of utmost importance
> that physicians remain aware of the disease as a possible diagnosis.
> Botulism should be considered whenever a patient develops
> neurological symptoms that include blurred vision, difficulties in
> swallowing or speech and symptoms of descending flaccid paralysis.
> This should be followed by appropriate epidemiological and laboratory
> analyses to confirm the diagnosis and to improve the epidemiological
> understanding of the disease (6).
>
> 1. Korkeala H, Stengel G, Hyytia E, et al: Type E botulism associated
> with vacuum-packaged hot-smoked whitefish. Int J Food Microbiol
> 1998;43: 1-5.
>
> 2. Hielm S, Bjorkroth J, Hyytia E, Korkeala H: Prevalence of
> Clostridium botulinum in Finnish trout farms: pulsed-field gel
> electrophoresis typing reveals extensive genetic diversity among type
> E isolates. Appl Environ Microbiol 1998;64: 4161-4167.
>
> 3. Hyytia E, Hielm S, Korkeala H. Prevalence of Clostridium botulinum
> type E in Finnish fish and fishery products. Epidemiol Infect 1998;
> 120: 245-50.
>
> 4. Lindstrom M, Nevas M, Hielm S, et al: Thermal inactivation of
> nonproteolytic Clostridium botulinum type E spores in model fish
> media and in vacuum-packaged hot-smoked fish products. Appl Environ
> Microbiol 2003;6: 4029-36.
>
> 5. Lindstrom M, Hielm S, Nevas M, et al: Proteolytic Clostridium
> botulinum type B in the gastric content of a patient with type E
> botulism due to whitefish eggs. Foodborne Pathog Dis 2004;1: 53-57.
>
> 6. Lindstrom M, Korkeala H: Laboratory diagnostics of botulism. Clin
> Microbiol Rev 2006;19: 298-314.
>
> [Written by: Lindstrom M, Vuorela M, Hinderink K, et al
> <markku.kuusi@ktl.fi>]
>
> - --
> ProMED-mail
> <promed@promedmail.org>
>
> [This report points out that storage temperature issues may also
> contribute to botulism.
>
> Prodromal symptoms of food-borne botulism often include nausea,
> vomiting, abdominal pain, and diarrhea, which are absent from cases
> of wound botulism. It is not clear that these symptoms are related
> to botulism per se or other contaminants of the ingested food. A USA
> paper (1) reported vomiting in 59 percent of foodborne cases and
> diarrhea in 19 percent; and one from the Republic of Georgia (2)
> reported vomiting in 56 percent and diarrhea in 25 percent.
>
> 1. Hughes JM, Blumenthal JR, Merson MH, et al: Clinical features of
> types A and B food-borne botulism. Ann Intern Med 1981;95: 442-45.
>
> 2. Varma JK, Katsitadze G, Moiscrafishvili M, et al: Signs and
> symptoms predictive of death in patients with foodborne botulism -
> Republic of Georgia, 1980-2002. Clin Infect Dis 2004;39: 357-62. -
> Mod.LL]
>
> [see also:
> Botulism, deer meat - Thailand (Phayao) 20060711.1901
> Botulism, bamboo shoots - Thailand (Nan)(03) 20060416.1131
> Botulinum toxin, laboratory exposure - USA (MA) (02) 20060410.1067
> Botulinum toxin, laboratory exposure - USA (MA) 20060408.1058
> Botulism, human, bamboo shoots - Thailand (Nan) 20060320.0865
> Botulism - Armenia (Erevan) 20060216.0505
> 2005
> - ----
> Botulism, canned food - Kyrgyzstan (Osh region) 20051219.3635
> Botulism, dried fish - Kazakhstan (Mangistauskaya) 20051017.3029
> Botulism, salted fish - Russia (Buryatia) 20051014.2998
> Botulism, canned food - Russia (Rostov) 20050712.1980
> Botulism - Russia (Komi) 20050705.1897
> Adult colonization botulism - Czech Rep. ex. Georgia (02): susp. 20050426.1159
> Adult colonization botulism - Czech Rep. ex Georgia: susp 20050420.1108
> Botulism, canned cucumbers - Russia (Samara) 20050228.0622
> Botulism, smoked fish - Russia (Rostov) 20050118.0167
> Botulism, dried fish - Ukraine (Zaporozhye) 20050220.0557
> Botulism during pregnancy - Kyrgyzstan (Chuysk) 20050218.0538
> Botulism, bamboo shoots - Canada (AB, BC): recall 20050110.0083
> 2004
> - ----
> Botulism, dried fish - Ukraine (Kharkov) 20041030.2930
> Botulism, smoked fish - Russia (Buryatia) (03) 20040908.2508
> Botulism, smoked fish - Russia (Buryatia) 20040817.2278
> Botulism, dried fish suspected - Russia (Volgograd) 20040526.1424
> 2003
> - ----
> Botulism, canned corn - Ukraine 20031121.2888
> 2000
> - ----
> Botulism, foodborne - Russia 1999 20000229.0277
> 1999
> - ----
> Botulism, human - Russia (Burjatija) 19990907.1576
> 1998
> - ----
> Botulism, human - Japan (Tokyo) 19980816.1632]
> ............................ll/pg/jw
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-- Liz Brown Assistant Professor Alaska Sea Grant Marine Advisory Program School of Fisheries and Ocean Sciences University of Alaska Fairbanks PO Box 1549 Dillingham, Alaska 99576 907-842-1265 fax 907-842-3202 http://seagrant.uaf.edu/map
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