Botulizm. Botulism ERWXOLQXP WRNVLQL NDSVD\DQ JÕGDODUÕ VLQGLUHQOHUGH 2.

Transcription

1 Dr. Hakan Ekmekçi 1 'U ø +DOLO g]huro 2 'U +LNPHW <ÕOPD] 1 %RWXOL]P JHQHOOLNOH &ORVWULGLXP ERWXOLQXP WDUDIÕQGDQ UHWLOHQ ERWXOLQXP Q URWRNVLQOHULQLQ VHEHS ROGX X Q URSDUDOLWLN ELU KDVWDOÕNWÕU %RWXOLQXP WRNVLQOHUL ELOLQHQ HQ NXYYHWOL EL\RORMLN WRNVLQOHUGLU %X WRNVLQOHU KHPDWRMHQ \ROOD SHULIHULN NROLQHUMLN VLQDSVODUD XODúÕU YH LUUHYHUVLEO RODUDN Q URPXVN OHU NDYúDN YH GL HU SHULIHULN RWRQRP VLQDSWLN UHVHSW UOHUH ED ODQDUDN DVHWLONROLQ VDOÕQÕPÕQÕ EORNH HGHUOHU %RWXOL]PLQ NDUDNWHULVWLN EXOJXVX GHVHQGDQ VLPHWULN IODNV SDUDOL]LOL KLSRWRQLGLU 3DUDOL]LOHU \ ] EDú YH IDULQNV NDVODUÕQÕ HWNLOH\HQ ELODWHUDO NUDQL\DO VLQLU WXWXOXPX\OD EDúODU YH GDKD VRQUD WRUDNV YH HNVWUHPLWH NDVODUÕQD GR UX LOHUOHU 7DQÕ VHUXPGD GÕúNÕGD PLGH YH\D NXVPXN NDSVDPÕQGD WRNVLQLQ J VWHULOPHVL YH GÕúNÕGDQ & ERWXOLQXPXQ L]ROH HGLOPHVL LOH \DSÕOÕU ø\lohúph VROXQXP GHVWH L VÕYÕ YH HOHNWUROLW GHQJHVLQLQ VD ODQPDVÕ YH HQIHNVL\RQODUÕQ QOHQPHVL JLEL ED]Õ IDNW UOHUH ED OÕGÕU >7XUJXW g]do 7ÕS 0HUNH]L Anahtar Kelimeler: Clostridium botulinum, botulizm, nörotoksin, paralizi, infant, yara Botulism Botulism is a severe neuroparalytic disease produced by botulinum neurotoxins of Clostridium botulinum. Botulinum toxins are the most potent poisons for humans. These toxins are haematogenously disseminated to peripheral cholinergic synapses where toxins bind irreversibly to the receptor sites at the neuromuscular junction and other peripheral autonomic synaptic sites, and block acetylcholine release. The characteristic clinical finding of botulism is hypotonia with a descending symmetric flaccid paralysis which begins with bilateral cranial nerve impairment involving muscles of the face, head, and pharynx and then descends symetrically to involve muscles of the thorax and extremities. The clinical diagnosis of food-borne botulism can be confirmed by assaying the toxin in serum, feces, gastric or vomitus contents, and isolation of C. botulinum from the feces of the patient. Recovery depends upon several factors such as the effectiveness of respiratory care, maintenance of fluid and electrolyte balance, and prevention of infection. [Journal of Turgut Özal Medical Center 1998;5(1):87-96] Key Words: Clostridium botulinum, botulism, neurotoxin, paralysis, infant, wound Botulizm, genellikle Clostridium botulinum olmak ]HUH NORVWULGLXP W UOHULQLQ UHWWL L SRWHQW ELU SURWHLQ nörotoksin olan botulinum toksininin kraniyal sinirleri HWNLOHPHVL LOH EDúOD\DQ YH HNVWUHPLWHOHUGHQ NDXGDOH GR UX LOHUOH\HQ Q URSDUDOLWLN ELU KDVWDOÕNWÕU %X ROJXODU NDWHJRUL\H D\UÕODELOLU 1. *ÕGD N NHQOL botulizm ROJXODUÕ C. botulinum'la kontamine olan ve ERWXOLQXP WRNVLQL NDSVD\DQ JÕGDODUÕ VLQGLUHQOHUGH 2. øqidqw ERWXOL]PL ROJXODUÕ JDVWURLQWHVWLQDO WUDNWXVXQGD C. botulinum kolonizasyonu ve botulinum nörotoksini UHWLOPLú RODQ D\OÕNWDQ N o N LQIDQWODUGD 3. Yara botulizmi ROJXODUÕ WRNVLQ UHWHELOHQ RUJDQL]PDODU LOH NRQWDPLQH WUDYPDWLN \DUDOÕ LQVDQODUGD ve 4. 6ÕQÕIODQGÕUÕODPD\DQ ROJXODU ise tespit edilebilen bir 1 2 øq Q hqlyhuvlwhvl 7ÕS )DN OWHVL 1 URORML $QDELOLP 'DOÕ 0DODW\D øq Q hqlyhuvlwhvl 7ÕS )DN OWHVL 0LNUREL\RORML YH.OLQLN 0LNUREL\RORML $QDELOLP 'DOÕ 0DODW\D Journal of Turgut Özal Medical Center 5(1):

2 H. Ekmekçi ve ark. EXODúPD YDVÕWDVÕ ROPDGDQ WLSLN ERWXOL]P VHPSWRP YH EHOLUWLOHUL J VWHUHQ ELU \DúÕQ ]HULQGHNL orfxnodugd görülmektedir (2). C. tetaniqlq UHWWL L Q URWRNVLQOHU LOH C. botulinum Q URWRNVLQOHULQLQ \DSÕ YH IRQNVL\RQX birbirlerine oldukça benzer, ancak sinir sisteminde IDUNOÕ K FUHOHUL KHGHIOHGLNOHUL LoLQ NOLQLN HWNLOHUL GUDPDWLN ELU ELoLPGH IDUNOÕGÕU %RWXOLQXP Q URWRNVLQOHUL WHPHOGH SHULIHUDO Q URPXVN OHU NDYúD Õ YH RWRQRPLN VLQDSVODUÕ HWNLOHU YH SULPHU RODUDN J ov ]O N úhnolqgh NHQGLQL J VWHULU 7HWDQR] WRNVLQL GH D\QÕ VLVWHPOHUL HWNLOH\HELOLU DQFDN VDQWUDO VLQLU sisteminin (SSS) inhibitör hücreleri üzerine olan HWNLOHUL GDKD EDVNÕQGÕU YH SULPHU RODUDN ULMLGLWH YH spazma neden olurlar. Hem botulizm hem de WHWDQR]XQ \ NVHN IDWDOLWH KÕ]ÕQD VDKLS ROPDVÕ YH KDVWD EDNÕP PDOL\HWOHULQLQ \ NVHN ROPDVÕ QHGHQL\OH EX KDVWDOÕNODUGDQ NRUXQPDN LoLQ H LWLP YH KDON VD OÕ Õ QOHPOHULQLQ QHPL J QFHOOL LQL NRUXPDNWDGÕU %RWXOL]POL KDVWDODUÕQ WÕL EDNÕP JLGHUOHULQLQ KDVWD EDúÕQD \DNODúÕN ROGX X KHVDSODQPÕúWÕU %X PDNDOHGH ERWXOL]P KDNNÕQGD ELOLQPHVL JHUHNHQ ELOJLOHU GHUOHQPLúWLU Botulizmin öyküsü XQFX \ ]\ÕOGD $YUXSDGD VRVLV YH GL HU HYGH KD]ÕUODQPÕú JÕGDODUÕ \L\HQOHUGH SDUDOL]LOHUOH VH\UHGHQ ]HKLUOHQPH VDOJÕQODUÕ J U OP úw U $OPDQ\D OÕ -XVWLQXV.HUQHU VRVLV ]HKLUOHQPHVL YDNDODUÕQÕ WDQÕPODPDN LoLQ ODWLQFH VRVLV DQODPÕQD JHOHQ botulus kelimesinden esinlenerek botulizm terimini NXOODQPÕúWÕU $\QÕ G QHPOHUGH 5XV\DOÕ ELU KHNLP benzer klinikli bir tabloyu EDOÕN ]HKLUOHQPHVL olarak WDQÕPODPÕúWÕU GH YDQ (UPHQJHQ WDUDIÕQGDQ KDVWDOÕ ÕQ HWNHQL RODQ C. botulinum WDQÕPODQPÕú YH hayvanlarda da insanlardakine benzer kas J ov ]O QH \RO DoDELOHQ ELU WRNVLQLQ EX PLNURRUJDQL]PD WDUDIÕQGDQ VDOJÕODQGÕ Õ J VWHULOPLúWLU 6RQUDNL \ÕOODUGD EX WRNVLQLQ WLS % ROGX X ELOGLULOPLú GH LVH WLS $ WDQÕPODQPÕúWÕU 1943 de yara botulizmi, 1976 da infant botulizmi WDQÕPODQPÕúWÕU \ÕOÕQGD LVH EHOLUOL ELU QHGHQ EXOXQDPD\DQ or XQOX X JDVWURLQWHVWLQDO kolonizasyonla ilgili olan sporadik vakalar WDQÕPODQPÕúWÕU 7LS $ WRNVLQ GD L]ROH HGLOPLúWLU Etiyolojik etken C. botulinum türleri, ]HOOLNOH WRSUDN GHQL]DOWÕ YH ]LUDL U QOHUGH ROPDN ]HUH WDELDWWD \D\JÕQ RODUDN bulunan subterminal sporlu, zorunlu anaerob, gram- SR]LWLI EDVLOOHUGLU (ULúNLQ LQVDQODU WD]H ]LUDL U QOHUOH DOGÕNODUÕ C. botulinum VSRUODUÕQÕ VLQGLUGLNOHUL LoLQ QRUPDO JDLWD IORUDVÕQGD EX PLNURRUJDQL]PD\D UDVWODQPDPDNWDGÕU huhwlohq toksinlerin antijenik spesifitelerine göre A dan G ye 8 PLNURRUJDQL]PD W U WDQÕPODQPÕúWÕU & WRNVLQOHULQLQ C 1 ve C 2 ROPDN ]HUH LNL WLSL YDUGÕU %RWXOLQXP toksinleri bilinen en kuvvetli biyolojik toksinlerdir..dq GRODúÕPÕQGDNL -9 mg/kg dozu insanlar için öldürücüdür. Tip A, B ve E toksin üreten türler VÕNOÕNOD WLS ) YH * WRNVLQ UHWHQ W UOHU LVH QDGLU RODUDN LQVDQODUGD LQIHNVL\RQODUD QHGHQ ROPDNWDGÕU )L]\RORMLN NDUDNWHUOHULQH J UH JUXSOX ELU VÕQÕIODPD VLVWHPL EHOLUOHQPLúWLU Grup 1 organizmalar kültürlerde proteolitiktir ve tip A, B ve F toksin üretebilirler. Grup 2 organizmalar nonproteolitiktir ve tip B, E ve F toksini üretebilirler. Grup 3 organizmalar tip C ya da D, Grup 4 ise tip G toksini üretirler. Tek cins sadece tek tip toksin üretir. Grup 2 organizmalar 25 C ile ƒ& DUDVÕQGD or DOÕUNHQ GL HU WLSOHU ƒ& LOH ƒ& DUDVÕQGD or DODELOPHNWHGLU +HU FLQV WLSLN RODUDN toksin kodlayan birkaç plasmid içerirken tip G bir adet SOD]PLG LoHUPHNWHGLU øqidqw ERWXOL]PLQH VHEHS olan C. butyricum ve C. baratii JLEL GL HU Clostridium W UOHULQLQ GH WRNVLQ UHWWL L J VWHULOPLúWLU C. botulinum WLSOHUL SURWHROLWLN DNWLYLWH LOH JÕGDODUGD pütrifikasyona neden olurken nonproteolitik tipler JÕGDODUGD GH LúLNOL H \RO DoPD]ODU A, B, E ve nadiren de F toksini üreten C. botulinum WLSOHUL LQVDQGD KDVWDOÕ D \RO DoDU * WRNVLQL üreten C. botulinum tipleri (günümüzde C. argentinense RODUDN DGODQGÕUÕOPDNWDGÕU DQL O PH VHEHS RODELOLU IDNDW Q URSDUDOLWLN KDVWDOÕ D \RO DoPD] +D\YDQODUGD WLS & YH ' KDVWDOÕNODUÕ GDKD VÕNWÕU øqvdqodugd ROGX X JLEL GL HU FDQOÕODUGD GD WDQÕ nörolojik bulgular ve toksinin gösterilmesi veya PLNURRUJDQL]PDQÕQ L]RODV\RQX LOH \DSÕOÕU Epidemiyoloji ' Q\DGD \D\JÕQ RODQ LQVDQODUGD J U OHQ ERWXOL]PLQ WHPHO IRUPX JÕGD N NHQOL NODVLN entoksikasyon formudur. Yara botulizmi en nadir olan KDVWDOÕN IRUPX LVH GH VRQ \ÕOODUGD $%' GH ELOGLULOHQ YDNDODUGD LON VÕUD\Õ DOPÕúWÕU 88 7XUJXWg]DO7ÕS0HUNH]L'HUJLVL

3 Ekmekçi H, et al. Botulism *ÕGD N NHQOL ERWXOL]P VÕNOÕNOD WRSOX ROXúXPODUGD WDQÕPODQÕUNHQ GL HU IRUPODUÕ VSRUDGLNWLU %RWXOLQXP WRNVLQ ND\QDNODUÕQÕ EX \ ]\ÕOÕQ EDúÕQGD HQ VÕN SL\DVDGD VDWÕODQ NRQVHUYHOHU ROXúWXUXU LNHQ J Q P ]GH HY \DSÕPÕ VHE]H PH\YH YH EDOÕN U QOHUL ROXúWXUPDNWDGÕU $ODVND \HUOLOHULQGH ROGX X JLEL ED]Õ N OW UOHUGH VÕNOÕNOD EDOÕN IHUPHQWDV\RQX LoLQ \DSÕODQ Q KD]ÕUODPD LúOHPL EHVLQOHUGH ERWXOLQXP WRNVLQOHULQLQ ROXúPDVÕQD \RO DoPDNWDGÕU %X ROJXODUGD HQ VÕN WLS ( WRNVLQ VXoODQPDNWDGÕU dlqgh ELOGLULOHQ HQ VÕN ND\QDN LVH HY \DSÕPÕ IHUPHQWH EH]HO\HGLU +DOHQ UHVWRUDQ \HPHNOHUL YH KD]ÕU JÕGDODU ND\QDN ROPD\D GHYDP HWPHNWHGLU %X U QOHULQ RUWDN ]HOOL L JHQHOGH S+ GH HULQLQ GDQ GDKD \ NVHN ROPDVÕGÕU $%' QLQ EDWÕVÕQGD WLS $ ERWXOL]PL GR XVXQGD LVH WLS % GDKD VÕNWÕU %X GD ÕOÕP EX E OJHOHUGH EXOXQDQ VSRU WLSOHULQL \DQVÕWPDNWDGÕU 7LS ) LVH GDKD D] WDQÕPODQPÕú FR UDILN GD ÕOÕP J VWHULU <DUD ERWXOL]PLQH GDKD orn WLS $ YH % RUJDQL]PDODUÕ QHGHQ ROXUODU LQIDQW ERWXOL]PL WLS $ % \D GD ) WDUDIÕQGDQ ROXúWXUXODELOLU %X NRQXGD HQ NDSVDPOÕ ND\ÕWODUÕ ROXúWXUDQ $%' GH \ÕOGD RUWDODPD NORVWULGL\DO besin zehirlenmesi epidemisinin ve infant ERWXOL]PLQLQ J U OG ELOGLULOPHNWHGLU $%'GH \ÕOOÕN V UHGH ELOGLULOHQ \DUD ERWXOL]PLQOHULQLQ L tip A, % 28 i tip B, % 2,1 i tip A ve tip B birlikte ve L WLSL ELOLQPH\HQ WRNVLQOHUH ED OÕ ROGX X WHVSLW HGLOPLúWLU øqidqw ERWXOL]PL or XQOXNOD EDO W NHWLPL LOH LOLúNLOHQGLULOLU ]LUD EDO GÕúÕ EHVOHQPH \N V RODQ LQIDQW ERWXOL]PL ROJXVX QDGLUGLU ønl LQIDQWGD WRSUDN NRQWDPLQDV\RQX DUDFÕOÕ Õ\OD ERWXOL]PLQ ROXúWX X ELOGLULOPLúWLU $\UÕFD LQIDQW botulizmin C. baratii ya da C. butyricum OH ELUOLNWHOL L J VWHULOPLúWLU (WL\RORMLVL ELOLQPH\HQ HULúNLQ ERWXOL]PLQGH HQ VÕN WLS $ WRNVLQL GDKD D] RUDQGD WLS % ve tip F toksini tespit edilmektedir (24). Tip F ERWXOL]P OL ELU HULúNLQ ROJX GD C. baratii izole HGLOPLúWLU LOH \ÕOODUÕ DUDVÕQGD +DVWDOÕN.RQWURO YH.RUXQPD 0HUNH]L QH &'& JÕGD N NHQOL YH WRSOX ROD\ ELOGLULOPLúWLU %X ROD\ODUGD RUWDODPD HWNLOHQHQ ROJX VD\ÕVÕ RODUDN KHVDSODQPÕúWÕU 7HN ROJXOX ROD\ODUGD JHQHOOLNOH HY \DSÕPÕ JÕGDODU VXoODQPÕúWÕU 5HVWRUDQ ND\QDNOÕ ELUGHQ ID]OD ROJXOX ROD\ODU W P ROD\ODUÕQ QÕ ROXúWXUPDNWDGÕU <R XQ EDNÕP X\JXODPDODUÕQGDNL JHOLúPHOHU QFHVL IDWDOLWH Õ DúDUNHQ OHULQ EDúÕQGD EX GH HU H DUDVÕQGD LVH D LQGLULOPLúWLU \DúÕQGDQ E \ N YDNDODUGD O P KÕ]Õ GXU øon HWNLOHQHQ ROJXODU ³LQGHNV ROJX RODUDN DQÕOÕU øqghnv ROJXODUGD HQWRNVLNDV\RQD ED OÕ IDWDOLWH RUDQÕ LNHQ VRQUDNL YH HUNHQ WDQÕ NRQXODQ olgularda fatalite riski % 4 dür (27). %RWXOL]P KD\YDQODU DOHPLQGH GDKD VÕNWÕU øqvdqodugdnl HWNLQ IRUPX GDKD orn WLS $ YH % LNHQ NXúODU DOHPLQGH YH LQVDQ GÕúÕ PHPHOL W UOHUGH WLS & GLU (13). Clostridium botulinum VSRUODUÕ G Q\DQÕQ KHU DODQÕQGD WRSUDN UQH LQGH YH GHQL] WRUWXVXQGD EXOXQXU (28). Bu sporlar 1 atm de 100 C ye birkaç saat GD\DQDELOPHNWHGLU.RQVHUYH JÕGDODUÕQ KD]ÕUODQPDVÕ DPDFÕ\OD \DSÕODQ ND\QDWPD LúOHPL VÕUDVÕQGD VROXV\RQODUÕQ DQDHURELN ]HOOL L DUWPDNWD YH GDKD VRQUD ÕVÕ\D GD\DQÕNOÕ VSRUODUGDQ ROXúDQ C. botulinumun için uygun bir ortam haline gelmektedir 6X\XQ ND\QDPD QRNWDVÕQÕQ G ú N ROGX X \ NVHN UDNÕPOÕ E OJHOHUGH NRQVHUYH JÕGD KD]ÕUODQPDVÕQGD X\JXQ G G NO WHQFHUHOHULQ NXOODQÕOPDVÕ LOH VSRUODU öldürülebilmektedir. Patogenez *ÕGD N NHQOL ERWXOL]P LoLQGH WRNVLQ UHPLú JÕGDODUÕQ \HQPHVL VRQXFX ROXúXU $OÕQDQ WRNVLQ öncelikle duodenum ve jejenumdan emilip kana NDUÕúDUDN SHULIHUDO NROLQHUMLN VLQDSVODUD XODúÕU Q URPXVN OHU ELOHúNH GDKLO <DUD ERWXOL]PL YDNDODUÕQGD VSRUODUÕQ \DUD LoLQGH JHUPLQH ROPDVÕ YH lokal toksin üretilmesi, infant ve kökeni bilinmeyen ERWXOL]P YDNDODUÕQGD LVH VSRUODUÕQ D Õ] \ROX\OD DOÕQÕPÕ söz konusudur. Aklorhidri ve antibiyotikler C. botulinum um gastrointestinal kolonizasyonuna neden RODELOLU.OLQLN EXOJXODU WRNVLQLQ UHGL L \HUGHQ ]L\DGH WLSLQH ED OÕGÕU 7DQÕPODQPÕú VHNL] WRNVLQ WLSLQGHQ $ % & 1, C 2, D, E, F, G), C 2 hariç tümü nörotoksindir. C 2, klinik önemi bilinmeyen bir sitotoksindir. Sindirim sistemi YH\D \DUD \HULQGHNL ERWXOLQXP Q URWRNVLQL GRODúÕPD NDUÕúÕU YH Q URP VN OHU NDYúDN SRVWJDQJOLRQLN SDUDVHPSDWLN VLQLU XoODUÕ YH SHULIHULN JDQJOLRQODU olmak üzere periferik kolinerjik sinir terminallerine WDúÕQÕU 6DQWUDO VLQLU VLVWHPL HWNLOHQPH] $NWLI Q URWRNVLQLQ N'D ELU D ÕU ]LQFLU N'D YH bir de hafif zincir (50 kda) olmak üzere iki NRPSRQHQWL YDUGÕU 1 URWRNVLQLQ DNWLYLWHVL LoLQ ED]Õ EDVDPDNODUÕQ DúÕOPDVÕ JHUHNLU 0\RQ UDO ELOHúNHGH SUHVLQDSWLN VLQLU K FUHOHULQH ]J Q RODUDN ED ODQPDOÕ 2. Sinir hücresinde vezikül içine toksin girebilmeli, 3. Journal of Turgut Özal Medical Center 5(1):

4 H. Ekmekçi ve ark. Sitozol içinde transloke olabilmeli ve 4. 1 URHN]RVLWR] DSDUDWÕQÕQ WRNVLQ ELU olqnr HQGRSHSWLGD] WDUDIÕQGDQ SURWHROL]L LOH Q URWUDQVPLWWHU DVHWLONROLQ VDOÕQÕPÕ HQJHOOHQPHOLGLU ø\lohúph \HQL VLQLU WHUPLQDOOHULQLQ WRPXUFXNODQPDVÕ LOH JHUoHNOHúLU 6LQLU XoODUÕQGD \HQL SUHVLQDSWLN WHUPLQDOOHULQ ROXúPDVÕ LoLQ KDIWDOÕN ELU V UH JHUHNPHNWHGLU Botulinum toksini bir tek polipeptid zinciri olarak sentezlenir. Daha sonra bakteriyel proteaz ile ohqwlnohqhuhn KDILI ]LQFLUL WRWDO D ÕUOÕ ÕQ owh ELUL RODFDN úhnlogh LNL ]LQFLUH D\UÕOÕU 0ROHN OHU D ÕUOÕN ED]ÕQGD WLS $ WRNVLQ GR DGD EXOXQDQ HQ SRWHQW WRNVLQGLU 6SRUODUÕQ DNVLQH WRNVLQ ÕVÕ\D GX\DUOÕGÕU 'H LúLN WRNVLQ WLSOHUL GH LúLN SRVWVHQWHWLN basamaklardan geçebilirler (31)..DV EL\RSVLVLQGH \DSÕODQ PLNURHOHNWURG odoõúpdoduõqgd HQ odusõfõ EXOJX VRQ SODN SRWDQVL\HO (33 LQLQ NXDQWDO LoHUL LQGH D ÕU ELU D]DOPD YH (33 QLQ ODWDQVÕQGDNL EHOLUJLQ GH LúNHQOLNWLU Ancak spontan minyatür son plak potansiyelleri 0633 QLQ QH DPSOLW G QGH QH GH IUHNDQVÕQGD D]DOPD ROPD] %X EXOJXODU ERWXOL]PGH DVÕO ROD\ÕQ motor sinir terminallerinde kalsiyumun hücre içine DOÕQÕPÕ LOH LQG NOHQHQ X\DUÕP VRQUDVÕ VLQDSWLN YH]LN O VDOÕQÕPÕQGDNL LúOHPOHULQ ER]XOPDVÕQD \RO DoDQ nöromusküler iletimin presinaptik düzeyde çok güçlü ELU úhnlogh HQJHOOHQGL LQL J VWHUPHNWHGLU Klinik bulgular %RWXOL]P ROJXODUÕQGD NODVLN RODUDN VLPHWULN desendan güçsüzlükle birlikte akut, bilateral kraniyal Q URSDWL VDSWDQÕU &'&QLQ ERWXOL]P WDQÕ NULWHUOHUL RODQ úx EHOOL EDúOÕ EXOJXODU GLNNDWL ohnphnwhglu $WHú \RNWXU ELU HQIHNVL\RQ NRPSOLNDV\RQX ROPDGÕ Õ sürece), 2) Nörolojik bulgular simetriktir, 3) Hasta X\DQÕNWÕU 1DEÕ] QRUPDO \D GD KLSRWDQVL\RQ \RNOX XQGD \DYDúWÕU 'X\X ND\EÕ \RNWXU EXODQÕN J UPH KDULo øon LNL EXOJX ]HOOLNOH poliomiyelitin ekarte edilmesi için çok önemlidir. $\UÕFD EX NULWHOHUH X\PD\DQ LVWLVQDODU GD ELOGLULOPLúWLU *ÕGD N NHQOL ERWXOL]P JHQHOOLNOH SUHIRUPH KDOGH WRNVLQ LoHUHQ JÕGDODUÕQ DOÕQPDVÕQGDQ VRQUDNL LOH VDDW LoLQGH JHOLúLU %X V UH VDDW LOH J Q DUDVÕQGD GH LúHELOLU øqn EDV\RQ V UHVL QH NDGDU NÕVD LVH KDVWDOÕ ÕQ úlgghwl R NDGDU ID]ODGÕU øon QFH EXOEHU NDVODU HWNLOHQLU 'LSORSL \DNÕQ ELU QRNWD\D fokuslamada zorluk, disfoni, dizartri ve disfaji ortaya oõndu.rolqhumln RWRQRP VLQLU VLVWHPLQLQ HWNLOHQPHVL LOH W NU N VDOJÕVÕQGD D]DOPD D Õ] NXUXOX X ER D]GD D UÕ LOHXV YH ULQHU UHWDQVL\RQ RUWD\D oõndu %X G QHPGH EXODQWÕ NXVPD DEGRPLQDO D UÕ YH LVKDO GH olabilir. Hastalar, önce kollara daha sonra vücuda ve EDFDNODUD \D\ÕODQ J ov ]O NWHQ úlnd\hw HGHU Nörolojik muayenede kraniyal sinir disfonksiyonu WHVSLW HGLOLU ODWHUDO UHNWXV NDVÕQGD ]D\ÕIOÕN.UDQLDO VLQLU SWR]LV GLODWH SXSLOODODU UPH UHIOHNVLQGH D]DOPD YH PHGL\DO UHNWXV SDUD]LVLQH VÕN UDVWODQÕU Bu dönemden sonra desendan motor sinir tutulumu RUWD\D oõndu 6ROXQXP NDVODUÕ GDKLO SHULIHULN NDVODU HWNLOHQLU %D]Õ KDVWDODUGD SDUDOL]L KDILI LNHQ GL HUOHULQGH KDIWDODUFD \R XQ GHVWHN WHGDYLVLQL JHUHNWLUHELOLU ùxxu DoÕNWÕU DWHú J U OPH] Q URORMLN GLVIRQNVL\RQ YDUGÕU DQFDN VLPHWULN ROPD\DELOLU 3XSLOOHU UHDNVL\RQ PRWRU L\LOHúPHGHQ D\ODU VRQUD ELOH DQRUPDO NDODELOLU 1LVWDJPXV VÕNOÕNOD J U O U VÕNOÕNOD GD WLS $ KDVWDOÕ ÕQGD ROXU øqjlowhuh GH RUWD\D oõndq YH \D\ÕQODQPÕú HQ E \ N WRSOX ERWXOL]P ROD\ÕQGD ROJXODUÕQ VLQGH Q URRIWDOPLN EXOJX\D UDVWODQPÕúWÕU %X JUXSWDNL D ÕU ROJXODUGD RN OHU YH bulbar semptomlar birlikte görülürken, hafif olgularda LON QFH GLVIDML JHOLúPHNWH YH DUGÕQGDQ VDDW LoLQGH YL] HO HWNLOHQPH J U OPHNWHGLU 'LNNDWL ohnhq GL HU bir husus ise respiratuar paralizi ve yetmezlik tespit HGLOHQ ROJXODUGD VROXQXP VLVWHPL EXOJXODUÕQÕQ NUDQL\DO VLQLU SDUDOL]LQLQ EDúODQJÕFÕQGDQ VRQUDNL LON VDDWWH ROXúPDVÕGÕU $OW NUDQL\DO VLQLU GLVIRQNVL\RQODUÕ GLVIDML GL]DUWUL KLSRJORVVDO güçsüzlük olarak görülür. Respiratuar disfonksiyon; \D VROXQXP HVQDVÕQGD ]D\ÕIODPÕú JORWWLVLQ NDSDQPDVÕ nedeniyle üst solunum yolu obstruksiyonu ya da GLDIUDJPD NDVÕQÕQ J ov ]O VRQXFX ROXúDELOLU %X WDEOR\D VDKLS KDVWDODUÕQ PHNDQLN YHQWLODV\RQ JHUHNVLQLPL YDUGÕU C. botulinum besin zehirlenmesinde esas ölüm sebebi respiratuvar veya EXOEHU SDUDOL]L YH GHVWHN WHGDYLVL VÕUDVÕQGD RUWD\D oõndq LQIHNVL\ ] NRPSOLNDV\RQODUGÕU Otonom sinir sistemi ile ilgili problemler; JDVWURLQWHVWLQDO GLVIRQNVL\RQODU LVWLUDKDW NDOS KÕ]ÕQGD GH LúPH SRVWXUDO GH LúLNOL H YH\D KLSRWDQVL\RQD FHYDEÕQ ND\EROPDVÕ KLSRWHUPL YH\D ULQHU UHWDQVL\RQGXU.ROLQHUMLN EORNDM LOH RUWD\D oõndq Q URPXVN OHU YH RWRQRPLN HWNLOHU ùhnlo GH ]HWOHQPLúWLU $\UÕFD ED ÕUVDN NRORQL]DV\RQ ERWXOL]PL WDQÕPODQPÕúWÕU drn QDGLU ELU WDEOR ROPDVÕQD UD PHQ EDúODQJÕoWD LQFH ED ÕUVDN IRQNVL\RQXQGD GH LúLNOLN 90 7XUJXWg]DO7ÕS0HUNH]L'HUJLVL

5 Ekmekçi H, et al. Botulism Nöromusküler etkiler 1 URPXVN OHU NDYúDNWDNL nikotinik kolinerjik iletimdeki azalma iskelet NDVODUÕQGD ]D\ÕIODPD\D QHGHQ olur Otonomik etkiler 3DUDVHPSDWLN Q URQODUÕQ VLQDSVODUÕQGD PXVNDULQLN kolinerjik iletimdeki azalma otonom disfonksiyona neden olur ùhnlo. %RWXOL]PLQ ROXúWXUGX X NROLQHUMLN EORNDMÕQ NOLQLN görünümü. gözlenen ve desendan paralizi ile seyreden olgularda akla gelmelidir (39). 'H LúLN WLS WRNVLQOHULQ HQWRNVLNDV\RQODUÕQGD UDVWODQDQ NOLQLN EXOJXODUGDNL IDUNOÕOÕNODUÕ DQDOL] DPDFÕ\OD OLWHUDW UGHNL YHULOHU 7DEOR GH ]HWOHQPLúWLU (17, 29, 40, 41). 7LS $ DQODPOÕ GHUHFHGH VÕNOÕNWD GL]DUWUL EXODQÕN J UPH GLVSQH GL\DUH ER D] D UÕVÕ EDúG QPHVL pitoz, oftalmopleji, fasiyal parezi ve üst ekstremite J ov ]O LOH ELUOLNWHGLU 7LS % YH ( GDKD orn otonomik disfonksiyon ile seyreder. Ancak bu IDUNOÕOÕNODUÕQ KLo ELUL WRNVLQ WLSLQLQ GLDJQRVWLN EXOJXVX GH LOGLU +DVWDODUÕQ VLQGHQ GDKD D]Õ GLODWH YH\D ÕúÕ D \DQÕWVÕ] SXSLOODODUD VDKLSWLU YDUOÕNODUÕ WDQÕ DoÕVÕQGDQ ROGXNoD QHPOL EXOJXODUGÕU \RNOX X LVH KLoELU úhnlogh ERWXOL]P RODVÕOÕ ÕQÕ D]DOWPD] øqidqw ERWXOL]PL NRQVWLSDV\RQOD EDúODU VRQUDNL G QHPGH EHVOHQPH J oo KLSRWRQL VDO\DGD DUWPD YH ]D\ÕI D ODPD RUWD\D oõndelolu %D]HQ LON EXOJX entübasyon gerektirecek kadar ciddi olan üst solunum \ROX REVWUXNVL\RQXGXU $ ÕU ROJXODUGD NUDQL\DO VLQLU Q URSDWLOHUL VROXQXP J ov ]O YH \H YDUDQ VROXQXP \HWPH]OL L WHVSLW HGLOLU %X WDEOR Tablo 1 %RWXOL]PLQ WLSOHULQLQ EXOJX YH VHPSWRPODUÕ Nörolojik semptomlar Dizfaji $ Õ] NXUXOX X Diplopi Dizartri Kollarda güçsüzlük Bacaklarda güçsüzlük %XODQÕN J UPH Dispnea Paresteziler Gastrointestinal bulgular Konstipasyon %XODQWÕ Kusma Abdominal kramplar Diare 'L HU VHPSWRPODU Yorgunluk %R D] D UÕVÕ %DúG QPHVL Nörolojik bulgular Pitoz Gag refleksinde azalma Oftalmoparezi Fasiyal paralizi Dilde güçsüzlük Dilate veya fiks pupiller Nistagmus Kollarda güçsüzlük Bacaklarda güçsüzlük Ataksi '75 OHULQGH D]DOPDDOÕQDPDPD DTR lerde hiperaktivite %DúODQJÕoWDNL PHQWDO GXUXP.ROD\ X\DUÕOPD Letarji 6WXSRUNRQI ]\RQ DUDVÕ Tip A (%) Tip B (%) Tip E (%) ÕVDOWPDODU (( (OGH HGLOHPHPLú '75 'HULQ WHQGRQ UHIOHNVL KDIWD V UHU ø\lohúph EDúODPDGDQ QFH KDIWDOÕN ELU G QHP LoLQ VWDELOOHúLU øqidqw ERWXOL]PGH relapslar olabilir (45). Oldukça nadir görülen, ancak HUNHQ WDQÕ YH \HWHUOL \R XQ EDNÕP GHVWH L LOH WDPD \DNÕQ L\LOHúPH ELOGLULOHQ LQIDQW ERWXOL]PL JHQHOGH X]XQ hospitalizasyon gerektirir (46). <DUD ERWXOL]PL JÕGD N NHQOL IRUPXQ SURGURPDO JDVWURLQWHVWLQDO ER]XNOXNODUÕQÕ J VWHUPH] DQFDN GL HU \ QOHUL\OH EHQ]HUGLU $WHú YDUVD QHGHQL ERWXOL]PGHQ ziyade yara enfeksiyonunudur. Nadiren nörolojik WDEOR JHOLúWL L DQGD \DUDQÕQ NHQGLVL L\LOHúPLú RODELOLU Aksine C. botulinum enfeksiyonu abse yapabilir (47)..RNDLQ ED ÕPOÕVÕ ELU KDVWDGD EX RUJDQL]PDQÕQ QHGHQ ROGX X VLQX]LW YH ERWXOL]P WHVSLW HGLOPLúWLU %LOGLULOHQ LQN EDV\RQ SHUL\RGX LOH J Q DUDVÕQGD GH LúPHNWHGLU Journal of Turgut Özal Medical Center 5(1):

6 H. Ekmekçi ve ark. /LWHUDW UGH NODVLN Q URORMLN EXOJXODU \DQÕVÕUD ELOLQHQLQ DNVLQH GX\VDO ER]XNOXNODUÕQ GD ELUOLNWH VH\UHWWL L EHOLUWLOHQ ROJX VXQXPODUÕ GD PHYFXWWXU %X GXUXPGD WDQÕGD UHSHWHWLI VLQLU X\DUÕPÕ YH HGURIRQLXP HQMHNVL\RQX LOH GHNULPHQWDO \DQÕWÕQ D]DOGÕ ÕQÕQ J VWHULOPHVLQLQ ROGXNoD QHPOL ROGX X YXUJXODQPDNWDGÕU 7DQÕ ù SKHOHQLOHQ ERWXOL]PLQ WLSLQH X\JXQ \N HQ QHPOL WDQÕVDO WHVWWLU %DúNDODUÕ GD HWNLOHQPLúVH GXUXPXQ WDQÕQPDVÕ orn GDKD NROD\ RODFDNWÕU <LQH GH WRNVLQ \L\HFHN JÕGDODUD WDP GD ÕOPDPÕú RODELOHFH L LoLQ EDúND KDVWDQÕQ \RNOX X WDQÕ\Õ RUWDGDQ NDOGÕUPD] /DERUDWXYDU GH HUOHQGLUPHVLQGH VHUXP JDLWD PLGH NDSVDPÕ YH XODúÕODELOL\RUVD NRQWDPLQH JÕGDQÕQ LQFHOHQPHVL JHUHNLU 'ÕúNÕ YH JÕGDGDQ N OW U \DSÕODUDN C. botulinum DUDúWÕUÕOÕU YH KD\YDQ GHQH\L LOH ERWXOLQXP WRNVLQL DUDúWÕUÕOÕU 7RNVLQ WLSOHPHVL YH GR UXODQPDVÕ YDNDGD P PN Q ROPDNWDGÕU (UNHQ ROJXODUGD GDKD orn WRNVLQ odoõúpdvõ\od LOHUOHPLú ROJXODUGD LVH WRNVLQGHQ ]L\DGH SR]LWLI N OW U VRQXFX LOH WDQÕ NRQXU guqhnohu X\JXQ HSLGHPL\RORMLN NRúXOODUGD DOÕQPDOÕ YH VDNODQPDOÕGÕU 7RNVLQ LoLQ HQ GX\DUOÕ WHVW IDUH GHQH\LGLU Toksinin letal etkisini göstermek için incelenecek materyaller fare peritonuna enjekte edilir, letal etkinin WLSH VSHVLILN DQWLVHUXP YHULOHQ IDUHOHUGH ND\ÕS ROGX XQXQ J VWHULOPHVL GH JHUHNLU )DUH GHQH\LQH alternatif olarak, antijen tespit eden ELISA kitleri JHOLúWLULOPLú ROPDVÕQD UD PHQ \D\JÕQ RODUDN NXOODQÕOPDPDNWDGÕU %RWXOL]P NOLQLN EHOLUWLOHULQL J VWHUHQ KDVWDODUÕQ QGH VHUXPGD QGH GÕúNÕGD WRNVLQ WHVSLWL LOH QGH LVH GÕúNÕGDQ PLNURRUJDQL]PDQÕQ L]ROH HGLOPHVL LOH WDQÕ konulabilmektedir. Alternatif olarak toksin ELISA ile WHVSLW HGLOHELOLU +DVWDOÕ ÕQ EDúODQJÕFÕQGDQ LWLEDUHQ WRNVLQ DWÕOÕPÕ D\ ER\XQFD V UHELOLU EX SHULRGGD JDLWD kültürleri pozitif kalabilir. $NXW IODNV SDUDOL]L JHOLúHQ KDVWDODUGD ]HOOLNOH bilateral 6. kranial sinir disfonksiyonu, gastrointestinal VHPSWRPODU EHOLUOL ELU JÕGD \HPH \N V YH EX JÕGDGDQ \L\HQ EDúND KDVWDODUGD GD D\QÕ VHPSWRPODUÕQ VDSWDQPDVÕ KDOLQGH ERWXOL]PGHQ ú SKHOHQPHN JHUHNLU %RWXOL]P ROJXODUÕQÕQ P\DVWHQLD JUDYLV (DWRQ/DPEHUW sendromu, kene paralizisi, Guillain-Barré sendromu, 3ROLR KLSHUPDJQH]HPL GLIWHUL ED]LOHU DUWHU GDOODUÕQÕ LOJLOHQGLUHQ VHUHEURYDVN OHU ROD\ODU WULúLQR]LV hipokalsemi, organofosfat zehirlenmesi, atropin LQWRNVLNDV\RQX YH SVLNL\DWULN VHQGURPODUOD D\ÕUÕFÕ WDQÕVÕQÕQ \DSÕOPDVÕ JHUHNLU 0\DVWHQLD JUDYLV ve Lambert-Eaton myastenik sendromu (LEMS) ERWXOL]PLQ ED]Õ RUWDN ]HOOLNOHULQL SD\ODúÕU DQFDN bunlar nadiren fulminan olurlar ve otonomik bulgu J VWHUPH]OHU (GURIRQLXP WHVWLQGH NXYYHWWHNL L\LOHúPH P\DVWHQLD JUDYLVH SDWRJQRPRQLN GH LOGLU ERWXOL]PGH de tespit edilebilir (50). Kene paralizisi iyi bir fizik PXD\HQH LOH D\ÕUW HGLOHELOLU ]LUD Dermacentor keneleri KDOHQ \DSÕúÕN RODFDNWÕU.ODVLN DNXW HQIODPDWXDU polinöropati (AIPN, Guillain-Barré Sendromu) VÕNOÕNOD PRWRU \DNÕQPDODUOD EDúODU KÕ]OD DUHIOHNVLN ROXU QDGLUHQ NUDQL\DO VLQLU GLVIRQNVL\RQX EDúODU YH SXSLOOHU WXWXOXP J VWHUPH] %RWXOL]PGH HWNLOHQPLú NDV JUXEX WDP SDUDOLWLN ROPDGÕ Õ V UHFH DUHIOHNVL ROPD] $,31 OL KDVWDQÕQ VHUXPX IDUHGH SDUDOL]L\H QHGHQ ROPDNWDGÕU %X QHGHQOH IDUH GHQH\L LOH ERWXOL]PGHQ D\ÕUW HGLOHPH] $,31 QLQ 0LOOHU )LVKHU YDU\DQWÕQGD RNXORPRWRU GLVIRQNVL\RQ VDSWDQÕU GL HU NUDQL\DO VLQLU WXWXOXPX RODELOLU DQFDN ERWXOL]PGH J U OPH\HQ EHOLUJLQ DUHIOHNVL YDUGÕU 3ROLR OX KDVWDODUGD EDúODQJÕoWD DWHú YH DVLPHWULN kuvvetsizlik mevcuttur. Magnezyum entoksikasyonu botulizmi taklit edebilir (51). (OHNWURIL]\RORMLN WDQÕ %RWXOL]PLQ GL HU Q URORMLN VHQGURPODUGDQ D\ÕUW edilmesi için 40 Hz veya daha yüksek frekansta UHSHWLWLI VWLPXODV\RQOX HOHNWURP\RJUDIL NXOODQÕODELOLU Botulizme ait elektrofizyolojik anormallikler EDúODQJÕoWD ROPD\DELOLU (WNLOHQHQ NDVODUGD ELOHúLN NDV DNVL\RQ SRWDQVL\HO DPSOLW GOHUL N o NW U DQFDN VLQLU LOHWL odoõúpdoduõ QRUPDOGLU %D]Õ KDVWDODUGD G ú N IUHNDQVOÕ VLQLU LOHWL X\DUÕPÕQGD GHNUHPHQWDO SDWHUQ J ]OHQHELOLU %X WHVW ROGXNoD D UÕ vericidir, ancak botulizm veya LEMS ciddi olarak G ú Q OG QGH \DSÕOPDOÕGÕU %RWXOL]P HOHNWURIL]\RORMLN RODUDN /(06 GHQ D\UÕODELOLU 7HN OLI (0* GH LVH EHOLUJLQ DUWPÕú MLWWHU YH EORN J ]OHQLU %X EXOJXODU /(06 GHNLQH EHQ]HU úhnlogh ERúDOÕP KÕ]Õ DUWWÕNoD D]DOPD J VWHUHELOLU øqidqw ERWXOL]PLQGHNL HOHNWURIL]\RORMLN EXOJXODU HULúNLQGHNLOHUH EHQ]HUOLN J VWHULU 7DQÕGD úx WULDG NDEXO J UP úw U 1. ' ú N DPSOLW GO ELOHúLN NDV DNVL\RQ SRWDQVL\HOL 2. Tetanik ve posttetanik fasilitasyon, 92 7XUJXWg]DO7ÕS0HUNH]L'HUJLVL

7 Ekmekçi H, et al. Botulism 3. 3RVWWHWDQLN W NHQPHQLQ ROPDPDVÕ $\UÕFD HQ VÕN WDQÕPODQDQ EXOJX +] OLN X\DUÕ KÕ]ÕQGD GHQ ID]OD LQNUHPHQWDO SDWHUQLQ gözlenmesidir (42, 56). Tedavi %RWXOL]PGH RUWD\D oõndq HQ QHPOL NRPSOLNDV\RQ DQL VROXQXP GXUPDVÕGÕU %X QHGHQOH KDVWDODUGD YLWDO kapasitenin monitorize edilmesi ve ventilatör GHVWH LQLQ VD ODQPDVÕ JHUHNLU hvw VROXQXP \ROX REVWUXNVL\RQX \D GD GLDIUDJPD NDVÕ J ov ]O RODQ KDVWDODUÕQ PHNDQLN YHQWLODV\RQ JHUHNVLQLPL YDUGÕU 7DEOR (Q D ÕU WDEOR\X ROXúWXUDQ WLS $ YDNDODUÕQGD RUWDODPD J Q WLS % LoLQ LVH J Q mekanik ventilasyon gerekmektedir (37). C. botulinum besin zehirlenmesinde esas ölüm sebebi respiratuvar veya bulber paralizi ve destek tedavisi VÕUDVÕQGD RUWD\D oõndq LQIHNVL\ ] NRPSOLNDV\RQODUGÕU *DVWURLQWHVWLQDO VLVWHPGHNL WRNVLQLQ X]DNODúWÕUÕOPDVÕ DPDFÕ\OD KDVWDOÕ ÕQ HUNHQ ID]ÕQGD JDVWULN ODYDM NDWDUWLN YH P VKLO NXOODQÕODELOLU.DQGDNL WRNVLQL nötralize edebilmek için antitoksin, barsaklarda toksin UHWHQ PLNURRUJDQL]PD VD\ÕVÕQÕ D]DOWPDN LoLQ RUDO penisilinler verilmelidir. Özellikle ventilatör GHVWH LQGHNL YH \R XQ EDNÕPGDNL LOHUOHPHOHULQ HWNLVL\OH NORVWULGLDO EHVLQ ]HKLUOHQPHVL ROJXODUÕQÕQ ]HULQGHNL PRUWDOLWH KÕ]Õ XQ DOWÕQD G ú U OP úw U %X RUDQODU ERWXOL]P LoLQ GHVWHN WHGDYLQLQ QHPLQL YXUJXODPDNWDGÕU (QWXEDV\RQ NDUDUÕ úx WHPHOOHU ]HULQH RWXUWXOPDOÕGÕU 1. hvw VROXQXP \ROODUÕQÕQ \HWHUOLOL LQ \DWDN EDúÕQGD VD ODQPDVÕ 2. 9LWDO NDSDVLWHGHNL GH LúLNOLNOHU JHQHO DQODPGD PONJ GDQ GDKD G ú N ELU YLWDO NDSDVLWH Oo P entübasyon için yeterli endikasyondur). $\UÕFD KDVWDQÕQ HQW EH HGLOPHVL LoLQ S&2 2 nin DUWPDVÕ YH\D S2 2 QLQ G úphvl EHNOHQPHPHOLGLU Tetanozun aksine otonomik disfonksiyonlar ERWXOL]PGH orn KD\DWL WHKOLNH ROXúWXUPD] L\L YH X\JXQ KDYD \ROX YH YHQWLODWRU X\JXODQÕPÕ LOH ELU Tablo 2. Mekanik ventilasyon gereksinim yüzdesi Toksin ve olgu % Tip A Tip B Tip E øqghnv ROJX Toplu olgularda NRPSOLNDV\RQ JHOLúPHGLNoH KDVWD L\LOHúLU ' ú N EDVÕQoOÕ HQGRWUDNHDO W S YH \ NVHN YRO POH HQW EH HGLOPLú KDVWDODUGD WUDNHRVWRPL DoÕOPDPDOÕGÕU PHNDQLN nedenler hariç entübasyonun süresi de bu konuda QHPOL GH LOGLU ( HU KDOHQ NRQWDPLQH JÕGD JDVWURLQWHVWLQDO WUDNWXVGD EXOXQX\RUVD YH LOHXV JHOLúPHPLúVH SXUJDWLIOHU \DUDUOÕ RODFDNWÕU $QWLWRNVLQ WHGDYLVL WULYDODQ DW VHUXPX LOH \DSÕOÕU WLS $ % YH ( %LOGLULOPLú KLSHUVHQVLWLYLWH RUDQÕ LOH DUDVÕQGD GH LúPHNWHGLU $QDILODNVL\H RUDQÕQGD UDVWODQÕU $QWLWRNVLQ X\JXODQÕPÕ QFHVL GHUL WHVWL \DSÕOÕU 6WDQGDUW DQWLWRNVLQ GR]X KHU ELUL,8 tip A, 5500 IU tip B ve 8500 IU tip E kapsayan iki IODNRQGXU %LU IODNRQ LQWUDYHQ ] YH GL HUL LQWUDPXVN OHU \ROGDQ YHULOLU $ ÕU \D GD SURJUHVLI YDNDODUGD KHU G UW VDDWWH EX GR] WHNUDUODQÕU $QWLWRNVLQ tedavisi özellikle tip B ve tip E botulizmde çok \DUDUOÕGÕU øqvdq ERWXOLQXP LPPXQJOREXOLQL LQIDQW ERWXOL]PLQGH NOLQLN odoõúpdoduõq GÕúÕQGD KHQ ] NXOODQÕPD JLUPHPLúWLU Yara botulizmi olan hastalar, yara iyiye gidiyor gözükse bile debride edilmelidir. Anaerobik kültürler FHUUDKL G QHPLQGH DOÕQPDOÕGÕU $QWLWRNVLQLQ ORNDO X\JXODQÕPÕQÕQ \HUL WDP ELOLQPHPHNWHGLU $QWLEL\RWLN tedavisi tam net olmamamakla birlikte MU J QO N SHQLVLOLQ * VÕNOÕNOD QHULOLU (WNLOL ELU DOWHUQDWLI tedavi de metronidazol'dur. Aminoglikozidler ve WHWUDVLNOLQOHU Q URQ NDOVL\XP JLULúLQL ER]DUDN LQIDQW ERWXOL]PL N W OHúWLULUOHU %X HWNL HULúNLQGH ELOGLULOPHPLúWLU 1 URPXVN OHU NDYúDNWD DVHWLONROLQ VDOÕQÕPÕQÕ DUWÕUPDN DPDFÕ\OD PJNJ GR]XQGD JXDQLGLQ KLGURNORULW NXOODQÕOÕU $QFDN EX WHGDYLQLQ HWNLQOL L WH\LG HGLOPHPLúWLU %RWXOL]PLQ L\LOHúPHQLQ LON o D\ÕQGD HQ \ NVHN NDV J F QH XODúÕOPDVÕQD UD PHQ KDVWDODU ELU \ÕOD NDGDU X]DQDQ L\LOHúPH YH NXYYHWOHQPH J VWHULUOHU %RWXOL]POL KDVWDODUGD UXK VD OÕ ÕQÕ HWNLOH\HFHN NDOÕFÕ SVLNRORMLN GLVIRQNVL\RQODU GD J U OHELOLU %RWXOLQXP WRNVLQLQLQ WHGDYL DPDoOÕ NXOODQÕPÕ 1 URPXVN OHU NDYúDNWD IRQNVL\RQHO GHQHUYDV\RQD \RODoDQ ERWXOLQXP WRNVLQL EX ]HOOL L QHGHQL LOH ED]Õ NOLQLN WDEORODUGD WHGDYL DPDoOÕ NXOODQÕOPD\D EDúODPÕúWÕU.RQYDQVL\RQHO RODUDN WLS $ WRNVLQL NXOODQÕOPDNWDGÕU 7HPHO NXOODQÕP DODQÕ GLVWRQLOHUGLU Journal of Turgut Özal Medical Center 5(1):

8 H. Ekmekçi ve ark.. o N RUDQGD HQMHNVL\RQ WHNUDUODUÕ VRQXFX WLS $ WRNVLQLQH NDUúÕ DQWLNRU JHOLúHELOPHNWH EX GXUXPGD HWNLQ NHPRGHQHUYDV\RQ LoLQ GL HU WLS WRNVLQOHU VÕNOÕNOD WLS ) NXOODQÕOPDNWDGÕU Botulinum toksin, blefarospazmda % 95, spazmodik disfonide % 90, servikal distonide % 85, RURPDQGLEXODU YH HO GLVWRQLOHULQLQ E \ N NÕVPÕQGD HWNLQ RODUDN NXOODQÕOPDNWDGÕU (O YHYH\D NDID WUHPRUOX ROJXODUÕQ VLQGHQ ID]ODVÕQGD LúH \DUDPDNWDGÕU Tedavinin komplikasyonu, ilgili sahaya lokalize J ov ]O NOH VÕQÕUOÕGÕU guqh LQ EOHIDURVSD]P YH blefaroklonusdan sonra major problem pitoz olabilir (30, 66). Servikal distoni tedavisinde disfaji JHOLúHELOLU dr X NRPSOLNDV\RQODU LOH KDIWDGD spontan olarak çözülür (66). $FLO \DNODúÕP $OÕúÕOGÕN \ROODUÕQ GÕúÕQGD RUWD\D oõndq KDILI ERWXOL]P WDEORVX NROD\OÕNOD \DQOÕú WDQÕ DODELOLU %X QHGHQOH DNXW NUDQL\DO VLQLU GLVIRQNVL\RQODUÕQÕQ EXOJX YH VHPSWRPODUÕ RODQ ROJXODUÕQ D\ÕUÕFÕ WDQÕVÕQGD DFLO RODUDN ERWXOL]P PXWODND G ú Q OPHOLGLU Botulizm de dahil olmak üzere ciddi bir Q URPXVN OHU KDVWDOÕNOD NDUúÕODúDQ DFLO VHUYLV KHNLPOHULQLQ NOLQLN ER]XOPD\Õ YH PHYFXW NDV J ov ]O Q Q QHGHQLQL DUDúWÕUÕUNHQ \N IL]LN PXD\HQH YH Q URORMLN GH HUOHQGLUPHGHQ \ROD oõndudn JHQLú WDEDQOÕ D\ÕUÕFÕ WDQÕ ]HULQGH odoõúpdoduõ JHUHNLU (70). Korunma %HVLQ ]HKLUOHQPHVL ROJXODUÕQÕQ HVDV QHGHQL EHVLQOHUGHNL VSRUODUÕQ JHUPLQH ROPDVÕ YH WRNVLQ UHWLOPHVL ROGX X LoLQ EX W U ERWXOL]PGHQ NRUXQPDQÕQ HQ QHPOL \ROX JÕGDODUGDNL VSRUODUÕQ \RNHGLOPHVL germinasyonun inhibe edilmesi veya preforme haldeki WRNVLQLQ WDKULS HGLOPHVLGLU %X DPDoODUÕ JHUoHNOHúWLUPHN LoLQ,VÕ YH\D UDG\DV\RQ X\JXODQDUDN JÕGDODUGDNL VSRUODU WDKULS HGLOHELOLU 7LS A ve B C. botulinum VSRUODUÕ ND\QDPD\D ELUNDo VDDW GD\DQÕNOÕGÕU %X QHGHQOH ]HOOLNOH VX\XQ ND\QDPD QRNWDVÕ G ú N RODQ \ NVHN UDNÕPOÕ E OJHOHUGH EHVLQOHU GDKD X]XQ V UH SLúLULOPHOLGLU ' G NO WHQFHUHGH ƒ& ÕVÕGD HQ D] GDNLND SLúLULOPHOLGLU 7LS ( C. botulinum VSRUODUÕ ÕVÕ\D GD\DQÕNVÕ]GÕU ƒ&gh GDNLNDGD WDKULS ROXUODU *ÕGDODUGDNL VSRUODUÕQ JHUPLQDV\RQXQX QOHPHN DPDFÕ\OD JÕGDODUÕQ S+QÕQ G ú U OPHVL SLúLUGLNWHQ VRQUD GRQGXUDUDN VDNODQPDVÕ NXUXWXOPDVÕ YH\D WX] úhnhu \D GD VRG\XP QLWULW JLEL LQKLELW U PDGGHOHULQ HNOHQHUHN LúOHQPHVL YH KD]ÕUODQPDVÕ JHUHNLU 2OXúPXú WRNVLQLQ LQDNWLYH HGLOPHVL LoLQ JÕGDODUÕQ \HQPHGHQ QFH ƒ&gh YH\D ƒ&gh GDNLND ÕVÕWÕOPDVÕ JHUHNLU +DILI úlúnlqohúplú NRQVHUYH NXWXODUÕQGDNL JD]GD C. botulinum EXOXQDELOPHVL QHGHQL\OH DoÕOPDPDOÕGÕU %R]XOPXú J ] NHQ JÕGDODU WDGÕOPDPDOÕGÕU $ ÕU KDVWDOÕN JHoLULOPHVLQH UD PHQ ERWXOLQXP WRNVLQLQH NDUúÕ LPP QLWH JHOLúPHPHNWHGLU ]LUD UHNXUUHQV YDNDODUÕ ELOGLULOPLúWLU /DERUDWXYDU SHVRQHOL LoLQ GHQH\VHO DúÕODPD odoõúpdoduõ PHYFXWWXU KAYNAKLAR 1. Abrutyn E. Botulism. In: Petersdorf RG, Adams RD, Braunwald E, Isselbacher KJ, Martin JB, Wilson JD, ed(s). Principles of Internal Medicine. 14 th ed. McGraw-Hill New York 1998: Todd ECD. Costs of acute bacterial foodborne disease in Canada and the United States. Int J Food Microbiol 1989; 9: Kerner J. Neue Beobachtungen über die in Würtemburg so haüfig vorfallen Vergiftung durch den Genuss gerauchter Würst. Tubingen In: Damon SR, ed. Infections and Food Intoxications. Baltimore: Williams Wilkins 1928: Young JH. Botulism and the ripe olive scare of Bull Hist Med 1976; 50: van Ermengen E. Ueber einen neuen anaëroben Bacillus und seine Beziehungen zum Botulismus. Z Hyg Infekt 1897; 26: Landman G. Ueber die Ursache der Darmstadter Bohnen Vergiftung. Hyg Rundsch 1904; 14: Davis JB, Mattman LH, Wiley M. Clostridium botulinum in a fatal wound infection. JAMA 1951; 146: Midura TF, Arnon SS. Infant botulism: Identification of Clostridium botulinum and its toxin in faeces. Lancet 1976; 2: Chia JK, Clark JB, Ryan CA, et al. Botulism in an adult associated with foodborne intestinal infection with Clostridium Botulinum. N Eng J Med 1986; 315: Lamanna C, Mc Elroy OE, Eklund HW. The purification and crystallization of Clostridium botulinum type A toxin. Science 1946; 103: Cato EP, Geroge WL, Finegold SM. Genus Clostridium praemozski In: Smeath PHA, Mair NS, Sharpe ME, ed(s). Bergey s Manual of Systematic Bacteriology. v. 2. Baltimore: Williams Wilkins 1986: Eklund MW, Poysky FT, Habig WH. Bacteriophages and plasmids in Clostridium botulinum and Clostridium tetani and 94 7XUJXWg]DO7ÕS0HUNH]L'HUJLVL

9 Ekmekçi H, et al. Botulism their relationship to the production of toxin. In: Simpson LL, ed. Botulinum Neurotoxin and Tetanus Toxin. San Diego: Academic Press 1989: Hatheway CL. Botulism: the present status of the disease. Curr Top Microbiol Immunol 1995; 195: Shaffer N, Wainwright RB, Middaugh PJ, et al. Botulism among Alaska Natives. The role of changing food preparation and consumption practices. West J Med 1990; 153: Gao QY, Huang YF, Wu JG, et al. A review of botulism in China. Biomed Environ Sci 1990; 3: Centers for Disease Control and Prevention. Botulism and commercial pot pie-california. MMWR 1983; 32: 39-40, Hughes JM. Botulism. In: Scheld WM, Whitley RJ, Durack DT,ed(s). Infections of the Central Nervous System. New York: Raven Press 1991: Smith LDS. The occurrence of Clostridium botulinum and clostridium tetani in the soil of the United States. Health Lab Sci 1978; 15: Weber JT, Goodpasture HC, Alexander H, et al. Wound botulism in a patient with a tooth abscess: case report and review. Clin Infect Dis 1993; 16: Midura TF, Snowden S, Wood RM, et al. Isolation of Clostridium botulinum from honey. J Clin Microbiol 1979; 9: Spika JS, Shaffer N, Hargrett-Bean N, et al. Infant botulism in the United States: An epidemiologic study of cases occuring outside of California. Am J Public Health 1983; 73: Hurst DL, Marsh WW. Early severe infantile botulism. J Pediatr 1993; 122: Suen JC, Hatheway CL, Steigerwalt AG, et al. Genetic confirmation of the identities of neurotoxigenic Clostridium baratii and Clostridium butyricum implicated as agents of human botulism. J Clin Microbiol 1988; 26: Mac Donald KL, Cohen ML, Blake PA. The changing epidemiology of adult botulism in the United States. Am J Epidemiol 1986; 124: McCroskey LM, Hatheway CL, Woodruff BA, et al. Type F botulism due to neurotoxigenic Clostridium baratii from an unknown source in an adult. J Clin Microbiol 1991; 29: Centers for Disease Control and prevention. Botulism in the United States, Handbook for Epidemiologist, Clinicians, and Laboratory Workers. Atlanta: DHEW Tacket CO, Shandera WX, Mann JM, et al. Equine antitoxin use and other factors that predict outcome in type A foodborne botulism. Am J Med 1984; 76: Hauschild AHW. Clostridium botulinum. In: Doyle MP, ed. Foodborne Bacterial Pathogens. New York: Marcel Dekker 1989: Tacket CO, Rogawski MA. Botulism. In: Simpson LL, ed. Botulinum Neurotoxin and Tetanus Toxin. San Diego: Academic Press; 1989: Patten J. Neurological Differential Diagnosis; 2nd ed. Glaskow: Springer-Verlag Critchley EMR, Mitchell JD. Human Botulism. Br J Hosp Med. 1992; 43: Maselli RA, Burnett ME, Tonsgard JH. In vitro microelectrode study of neuromuscular transmission in a case of botulism. Muscle Nerve 1992; 15: Terranova W, Palumbo JN, Berman JG. Ocular findings in botulism type B. JAMA 1979; 241: Friedman DI, Fortanasce VN, Sadun AA. Tonic pupils as a result of botulism. Am J Ophthalmol 1990; 109: Simcock PR, Kelleher S, Dunne JA. Neuro-ophthalmic findings in botulism type B. Eye 1994; 8: Woodruff BA, Griffin PM, McCCroskey LM, et al. Clinical and laboratory comparison of botulism from toxin types A, B, and E in the United States J Infect Dis 1992; 166: Hughes JM, Blumenthal JR, Merson MH, et al. Clinical features of types A and B foodborne botulism. Ann Intern Med 1981; 95: Vita G, Girlanda P, Puglisi RM, et al. Cardiovascular-reflex testing and single fiber electromyography in botulism. A longitudinal study. Arch Neurol 1987; 44: Griffin PM, Hatheway CL, Rosenbaum, et al. Endogenous antibody production to botulinum toxin in an adult with intestinal colonization botulism an underlying Crohn s disease. J Infect Dis 1997; 175: Weber JT, Hibbs RG, Darwish A, et al. A massive outbreak of type E botulism associated with traditional salted fish in Cairo. J Infect Dis 1993; 167: Colerbatch JG, Wolff AH, Gilbert RJ, et al. Slow recovery from severe foodborne botulism. Lancet 1989; 2: Cornblath DR, Sladky JT, Sumner AJ. Clinical electrophysiology of infantile botulism. Muscle Nerve 1983; 6: Oken A, Barnes S, Rock P, et al. Upper airway obstruction and infant botulism. Anest Analg 1992; 75: Schreiner MS, Field E, Ruddy R. Infant botulism: A review of 12 years experience at the Children s Hospital of Philadelphia. Pediatricss 1991; 87: Glauser TA, Maquire HC, Sladky JT. Relapse of infant botulism. Ann Neurol. 1990; 28: Thomas DG. Infant botulism: a review in South Australia ( ). J Paediatr Child Health 1993; 29: Elston HR, Wang M, Loo LK. Arm abscesses caused by Clostridium botulinum. J Clin Microbiol 1991; 29: Kudrow DB, Henry DA, Haake DA, et al. Botulism associated with Clostridium botulinum sinusitis after intranasal cocaine abuse. Ann Inter Med 1988; 109: Kuruoglu R, Cengiz B, Tokçaer A. Botulism with sensory symptoms diagnosed by neuromuscular transmission studies associated with edrophonium responsiveness. Electromyogr Clin Neurophysiol 1996; 36: Edell TA, Sullivan CP, Osborn KM, et al. Wound botulism associated with a positive Tensilon test. West J Med 1983; 139: Cherington M. Botulism. Semin Neurol 1990; 10: Dunbar EM. Botulism. J Infect 1990; 20: Dowell VR, McCroskey LM, Hatheway CL, et al. Coproexamination for botulinal toxin and Clostridium Journal of Turgut Özal Medical Center 5(1):

10 H. Ekmekçi ve ark. botulinum. A new procedure for laboratory diagnosis of botulism. JAMA; 238: Notermans S, Nagel J. Assays for botulinum and tetanus toxins. In: Simpson LL, ed. Botulinum Neurotoxin and Tetanus Toxin. San Diego: Academic Press 1989: Notermans SHW, Wokke JHJ, van den Berg LH. Botulism and Guillain-Barré syndrome. Lancet 1992; 340: Sanders DB. Electrophysiologic study of disorders of neuromuscular transmission. In: Aminoff MJ ed. Electrodiagnosis in Clinical Neurology. 3rd ed. New York: Churchill Livingstone 1992: Gutman L, Prott L. Pathophysiologic aspects of human botulism. Arch Neurol 1976; 33: Schiller HH, Stalberg E. Human botulism studied with singlefiber electromyography. Arch Neurol 1974; 35: Gutierrez AR, Bodensteiner J, Gutmann J. Electrodiagnosis of infantile botulism. J Child Neurol 1994; 9: Barrett DH. Endemic food-borne botulism: Clinical experience, Alaska Med. 1991; 33: Frankovich TL, Arnonm SS. Clinical trial of botulism immune globulin for infant botulism. West J Med 1991; 154: Wilson R, Morris JG, Snyder JD, et al. Clinical characteristics of infant botulism in the United States: A study of the non- California cases. Pediatr Infect Dis 1982; 1: Kaplan JE, Davis LE, Narayan V, et al. Botulism, type A, and treatment with guanidine. Ann Neurol 1979; 6: Wilcox PG, Morrison NJ, Pardy Rl. Recovery of the ventilatory and upper airway muscles and exercise performance after type A botulism. Chest 1990; 98: Cohen FL, Hardin SB, Nehring SB, et al. Physical and psychosocial health status 3 years after catastrophic illnessbotulism. Issue Mental Health Nurs 1988; 9: Jankovic J, Schwartz K, Donovan DT. Botulinum toxin treatment of cranial-cervical dystonia, spasmodic dysphonia, other focal dystonias, and hemifacial spasm. J Neurol Neurosurg Psychiatr 1990; 53: Jankovic J, Brin M. Therapeutic uses of botulinum toxin. N Engl J Med 1991; 324: Jankovic J, Schwartz K. Botulinum toxin treatment of tremors. Neurology 1991; 41: Townes JM, Cieslak PR, Hatheway CL, et al. An outbreak of type A botulism associated with a commercial cheese sauce. Ann Intern Med 1996; 125: Lo Vecchio F, Jacobson S. Approach to generalised weakness and peripheral neuromuscular disease. Emerg Med Clin North Am 1997; 15: Beller M, Middaugh JP. Repeated type E botulism in an Alaskan Eskimo. N Engl J Med 1990; 322: 855. <D]ÕúPD DGUHVL 'U +DNDQ (.0(.dø øq Q hqlyhuvlwhvl 7ÕS )DN OWHVL Nöroloji ABD MALATYA 96 7XUJXWg]DO7ÕS0HUNH]L'HUJLVL