How Not to Die of Botulism

Highly-poisonous botulinum toxin (the stuff in Botox), played a formidable role in the history of food and warfare. It is still a factor in prison-brewed alcohol and some canned foods, and can quickly kill a person.
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(Andrew Dinh/flickr)

After tanking up on “pruno,” a bootleg prison wine, eight maximum-security inmates at the Utah State prison in Salt Lake County tried to shake off more than just the average hangover. Their buzz faded into double vision, weakness, trouble swallowing, and vomiting. Tests confirmed that the detainees came down with botulism from their cellblock science experiment. In secret, a prison moonshiner mixed grapefruit, oranges, powdered drink mix, canned fruit, and water in a plastic bag. For the pièce de résistance, he added a baked potato  filched from a meal tray weeks earlier and peeled with his fingernails. After days of fermentation and anticipation, the brewer filtered the mash through a sock, and then doled out the hooch to his fellow yardbirds.

The party was short-lived. The potato was a big mistake.

Investigators traced botulism spores to the humble spud. Within hours of the first swig, botulinum toxin infiltrated the prisoners’ nerve cells, causing weakness and paralysis. Three of the men required a breathing tube and ventilator to prevent suffocation. All eight victims received an experimental antitoxin from the Centers for Disease Control and Prevention, and thanks to meticulous supportive care, none died. But recovery from botulism takes weeks to months; the body must regrow new nerve endings to replace the poisoned ones. All told, the hospital bill topped their bar tab—more than $500,000 in fees alone, not including added expenses for transportation, security, and public health investigation.

Botulinum toxin, a protein produced by the bacterium Clostridium botulinum, could be “the most poisonous poison” there is, as writer Carl Lamanna called it in an article for Science, in 1959. First weaponized by Imperial Japan in the 1930s, and later, Nazi Germany, the United States, the Soviet Union, Syria, Iran, Iraq, and North Korea, a single gram of toxin could theoretically kill more than a million people if dispersed into the air and inhaled. But before botulinum toxin became a bioweapon and a smoother of crow's feet as the drug Botox, botulism was historically a foodborne malady, and the toxin lurked in sausage and cured meats.

Botulism, the illness caused by toxin exposure, first received scientific attention in rural Germany in the late 18th century. Officials in Stuttgart saw an increase in “sausage poisoning” in the wake of the Napoleonic wars, possibly due to poor sanitation and widespread poverty. In the 1820s, a young German physician named Justinus Kerner was the first scientist to publish an accurate and comprehensive description of the disease. He analyzed more than 200 cases of suspected sausage poisoning. He fed extracts of these “sour” sausages to animals and described the classic symptoms of botulism. Muscle weakness leading to drooped eye lids, difficulty swallowing, and respiratory failure; altered autonomic nerve function leading to vomiting, pupil dilation, and dry mouth. Brazenly, he sampled a few drops of this extract himself—he survived, though it caused a “great drying out of the palate and pharynx,” a harbinger of Botox’s modern application in treating uncontrollable salivation for those with amyotrophic  lateral sclerosis, or Lou Gehrig’s disease. Grateful citizens dubbed the scientist “Wurst-Kerner,” for his pioneering contributions to public health and sausagery. In 1870, another German physician renamed the illness “botulism” after the Latin word “botulus,” or sausage.

For centuries, people dried, smoked, fermented, canned, and neglected their food, naïve to the microbial threat festering within. This changed in the late 19th and early 20th centuries as science moved from the laboratory into the kitchen. In 1895, Émile van Ermengem isolated a spore-forming bacterium from the remnants of a salted ham that killed three musicians in a Belgian outbreak. He confirmed that Kerner’s mysterious sausage—or ham—poison was made by a microbe. Under very specific growth conditions, the active form of the bacterium could be coaxed to grow and produce toxin; under other conditions, the bacterium would retreat into a dormant, or spore form that does not do so.

Early 20th century researchers found Clostridium botulinum spores nearly anywhere: in soil, rivers, lakes, oceans, on vegetable surfaces, and in fish and animal intestines. Laboratory tests demonstrated that spores are durable: they withstand even boiling. When introduced into an optimal, low-oxygen environment—like the inside of a jar or can of food—spores germinate and make the toxin. Given the ubiquity of botulinum spores in the environment, it is surprising that outbreaks were not more frequent.

As food science matured into its own discipline, botulism outbreaks resulting from commercially canned foods dwindled. Food producers could stop toxin production by manipulating temperature, acidity, salt content, moisture, oxygen concentration, and food preservatives such as nitrates or nitrites. Pressure-cooking freshly canned goods at 250 degrees Fahrenheit destroys spores in 20 minutes, enabling safe long-term storage.

Modern foodborne outbreaks occur when botulism control methods are deliberately, or inadvertently, ignored. Homemade foods are now the leading cause of the disease in the U.S., which is not surprising, as only 59 percent of home canners preserving botulism-friendly low acid vegetables actually use a pressure sterilizing process, according to a National Center for Home Food Preservation survey. Fortunately, botulism remains rare nationwide: between 1990 and 2000, 160 outbreaks afflicted only 263 people. And advances in medical care, including antitoxin availability and intensive care units, have decreased the fatality rate from 60 percent in the first half of the 20th century to about 5 percent now.

But food safety improvements pioneered in the last century occasionally fail the most vulnerable consumers. Young babies now account for most botulism cases reported in the U.S. The cause of infant botulism remains unknown. Infants’ digestive systems are hospitable to Clostridium botulinum, perhaps because their gut bacteria and digestive juices are still immature. Ingested spores activate and produce toxin that is absorbed into the body. Afflicted babies become constipated and “floppy” as the relaxed paralysis takes hold. Like adults, they may require breathing support on a ventilator, but most recover. Early investigators identified honey as a possible spore source in about 20 percent of victims, but most cases remain unexplained—some have wondered whether spore-laden household dust could be the culprit.

Although botulism caused floppy babies for centuries, the first case report of infant botulism was published only in 1976. Around this time, American epidemiologists uncovered another botulism mystery: a geographic one. California, Oregon, Washington, and Alaska accounted for the majority of foodborne outbreaks from 1950 to 1996. They found one answer in Alaska.

For generations, indigenous Alaskans prepared traditional foods using available resources and recipes inherited from their ancestors. To preserve meat, they buried fresh animal parts in cool clay-lined pits to undergo controlled microbial decay under a layer of moss or grass. The final product is complex in flavor, rich in nutrients, portable, and safe from scavengers—no cooking needed! Scandanavians historically used a similar process to make gravlax, which literally translates to “grave salmon.” We now know that traditional preserved meats like seal, whale (“muktuk”), beaver tail (“stink tail”), and salmon heads (“stink heads”) can nurture Clostridium botulinum, much like Kerner’s sausage.

In the far North, as in Europe, foodborne botulism is nothing new. In 1913, explorer Vilhjalmur Stefansson reported a suspected botulism outbreak of “white whale poisoning” that killed eight Inuit. Alaskan botulism rates skyrocketed in the 1970’s and 80’s while remaining steady nationwide. This trend was likely caused by changes in food preservation practices, though better record keeping and detection of the illness probably contributed. As Alaska modernized, “stink” chefs substituted breathable earthen pits or animal skins with readily sourced vessels made of wood, glass, or plastic. New containers facilitate fast indoor fermentation without the hassle of digging. Better living through chemistry? Perhaps not. Investigators suspect that these well-sealed containers create a warm, oxygen-deprived environment more hospitable to botulinum spores.

In response to the botulism epidemic, Alaskan tribal and public health officials launched an educational campaign encouraging citizens to return to the traditional meat preservation methods of their forebears. Their message is counterintuitive—who could imagine that burying meat in the ground is less harmful than sealing it in a clean bucket? Some are heeding the advice, as Alaskan foodborne botulism is at its lowest since the 1960’s, despite remaining more than 800 times the national average. Declining popularity of “stink” foods could also  be contributing to the decline. Nonetheless, the Alaskan botulism experience serves as a culinary “I told you so” to younger generations. Sometimes, you shouldn’t mess with the recipe.

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Bradley Wertheim, MD, is an internal medicine resident at the Massachusetts General Hospital in Boston.

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