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An Outbreak of Type A Botulism Associated with a Commercial Cheese Sauce

John M. Townes, MD; Paul R. Cieslak, MD; Charles L. Hatheway, PhD; Haim M. Solomon, MS; J. Ted Holloway, MD; Michael P. Baker, MD; Charles F. Keller, BS; Loretta M. McCroskey, BS; and Patricia M. Griffin, MD
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From the Centers for Disease Control and Prevention and Georgia Department of Human Resources, Atlanta, Georgia; Southeast Health Unit, Waycross, Georgia; and U.S. Food and Drug Administration, Washington. D.C. Acknowledgment: The authors thank Dr. Edward W. Perkins for his contribution to the recognition of this outbreak. Requests for Reprints: John Townes, MD, Centers for Disease Control and Prevention, Foodborne and Diarrheal Diseases Branch, Mailstop A-38, Atlanta, GA 30333. Current Author Addresses: Drs. Townes and Cieslak: Center for Disease Prevention and Epidemiology, Oregon Department of Human Resources, Health Division, 800 Northeast Oregon Street, Suite 772, Portland, OR 97232.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1996;125(7):558-563. doi:10.7326/0003-4819-125-7-199610010-00004
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Background: Although botulism is rare, recognition of a possible case of this illness represents a public health emergency. To prevent more cases, prompt investigation must be done to determine whether illness is linked to a commercial product or restaurant. Botulism can masquerade as other illnesses, and seemingly unlikely foods can harbor botulinum toxin.

Objective: To confirm the diagnosis and determine the cause and extent of an outbreak of botulism associated with food served at a delicatessen.

Design: Retrospective cohort study of patrons of the delicatessen; laboratory analysis of food, serum samples, and stool samples; and traceback of implicated food.

Setting: Community in Georgia.

Participants: Patrons of the delicatessen.

Main Outcome Measures: Botulinum toxin in food, serum, or stool and Clostridium botulinum in food and stools.

Results: 8 of 52 patrons (15%) met the case definition for botulism. In 4 of the 8 patrons, an illness other than botulism was initially diagnosed. Five of the 8 were hospitalized, and 1 died. Stool cultures from 4 patrons yielded type A C. botulinum, and two serum samples contained botulinum toxin. All ill persons ate food from the delicatessen on 1 October 1993. Of the 22 persons who ate at the delicatessen that day, all 8 ill persons but none of the 14 well persons ate a potato stuffed with meat and cheese sauce. An open can of cheese sauce contained type A botulinum toxin and yielded C. botulinum on culture. Cheese sauce experimentally inoculated with C. botulinum spores became toxic after 8 days at a temperature of 22 °C (room temperature).

Conclusions: A commercial, canned cheese caused a botulism outbreak. This product readily becomes toxic when contaminated by C. botulinum spores and left at room temperature. Mild botulism caused by unusual vehicles may be misdiagnosed. Botulism should be included in the differential diagnosis of persons with signs or symptoms of acute cranial nerve dysfunction.


Grahic Jump Location
Figure 1. * = date of symptom onset in 8 patrons with botulism. Hatched bar = meals eaten by 8 patrons who developed botulism; white bars = meals eaten by patrons who remained well.
Date of meals eaten by all 52 patrons of the delicatessen and dates of symptom onset in 8 patrons with botulism.
Grahic Jump Location




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