‘Challenging’ botulism case highlighted in Australia; country reports recall information

More detail has been shared about the diagnosis of a patient who fell seriously ill after having almond milk in Australia.

A 61‐year‐old man suffered severe botulism symptoms in 2023 after drinking a dairy alternative. 

According to an article in The Medical Journal of Australia, it was the first botulism case in the country linked to a commercially prepared product since 2007.

As no suspected food poisoning was initially disclosed, brainstem stroke was the primary differential diagnosis.

On day 2, the patient developed vomiting, difficulty swallowing, and severe respiratory distress, requiring intubation. He subsequently had complete ophthalmoplegia (weakness or paralysis of eye muscles), descending flaccid paralysis, and required ventilation. A diagnosis of Miller-Fisher syndrome was then considered.

Link to almond milk
Further history on day 15 revealed the man had consumed foul‐tasting almond milk 12 to 36 hours before symptom onset. Botulism was then suspected.

Clostridium botulinum culture and test results were negative on a retained milk sample and stool. Results from the Clostridium botulinum direct toxin test using the mouse bioassay showed the presence of botulinum toxin in a retained milk sample. Another test on a retained milk sample detected botulinum toxin A nucleic acid.

On day 16, the patient was given botulin antitoxin. He was weaned off mechanical ventilation five months after admission to the intensive care unit.

Following notification of the suspected foodborne botulism case, Inside Out Nutritious Goods issued a national recall due to missing storage information: it had not been labeled with instructions to keep refrigerated. The product was sold chilled and needed to be kept in the fridge.

“This case was diagnostically challenging due to an initially limited history with rapidly progressive signs that overlapped between botulism, Miller-Fisher syndrome, and brainstem stroke. If botulism is suspected, antitoxin should be administered urgently,” said researchers.

Recall data
In other news, Food Standards Australia New Zealand (FSANZ) revealed 87 recalls were undertaken in 2023, up from 75 in 2022 but down from 109 in 2020.

Undeclared allergens were behind 41 recalls in 2023. The issue was identified by a consumer complaint on 19 occasions. Routine government or company testing was used to detect the problem several times. Microbial contamination prompted 23 recalls, seven of which were caused by foreign bodies.

The most common reasons for recalls from 2019 to 2023 were undeclared allergen and microbial contamination, while biotoxins and packaging faults accounted for a smaller proportion.

While a single undeclared allergen prompted most recalls, some were due to multiple allergens. The most common were milk, tree nuts, wheat/gluten, and eggs. 

Regarding root cause, errors during packaging were the main driver of allergen-related recalls, but challenges with supplier verification were also notable.

From 2019 to 2023, there were 83 food recalls due to microbial contamination. Thirty were caused by Listeria monocytogenes, 27 due to Salmonella, and 18 due to E. coli. There were also another 20 recalls due to potential microbial contamination. 

There were 39 recalls due to foreign matter, such as plastic and metal. Fourteen recalls were due to biotoxins such as patulin and histamine. Chemical contamination led to 24 recalls, the most common being thebaine and ethylene oxide.

In this period, the top recalled products were mixed and/or processed foods. This category includes most long-life packaged foods and manufactured items with multiple ingredients. Dairy products, breads and bakery products, fruit and vegetables, and confectionery were also commonly recalled. 

The main corrective actions were staff training, amended handling procedures, and improved communication processes. Other steps included increased testing and ceasing production or supply. The majority of food businesses reported undertaking more than one corrective action.

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