ABSTRACT
Objective: In September-October 2020 our Poison Centre (PC) managed a cluster of 44 workmen who consumed food contaminated by botulinum neurotoxins (BoNT) at a workplace canteen in Sicily. Case series: Of the 100 workers using the canteen, 44 presented over a 7-day period to 6 Emergency Departments (ED) in Southern Italy complaining of neurological and gastrointestinal symptoms (Table 1). Our PC, consulted first by physicians in Cefalù, made the diagnostic suspicion of foodborne botulism. Heptavalent-botulism-antitoxin (HBAT) was mobilized from different National Stockpiles (Catania, Pavia, Rome, Trieste, Naples) after approval from the Ministry of Health (MoH). The early admitted patients (7/44, 17%, 2-days after meal) worsened rapidly and 5/7 required mechanical ventilation (MV) within 24 hours. Patients with minor symptoms were discharged and managed with telephone follow-up by PC toxicologists. Conclusion: Botulism diagnosis is based on clinical suspicion;laboratory testing has a crucial role in confirmation, but analyses do not always demonstrate BoNT (15/36 tested positive in our cluster). Therefore, the positivity of at least 1 patient of a cluster confirms the diagnosis. The antitoxin should be administered as soon as clinical suspicion is made. In our outbreak, HBAT was administered due to rapid worsening of neurological symptoms, in order to prevent MV. The rapid deterioration of the first 7 patients is attributable to the ingestion of higher titre of toxin. In Italy, HBAT in the National Stockpile can be mobilized only after MoH approval. The management of the outbreak was challenging because of difficulties in the capacity of the hospitals and the urgent need for antitoxin. An efficient collaboration between local physicians, clinical toxicologists, MoH and the National Stockpile system ensured optimal management with prompt HBAT mobilization in sufficient number. This was also possible because it occured before the second COVID-19 wave in which it would have been difficult to manage 44 patients potentially requiring ICU monitoring.