Neurologists are most likely to become involved in primarily diagnosing those bioterrorist attacks utilising botulinum toxin. Oral ingestion, or possibly inhalation, are likely routes of delivery. The characteristic descending paralysis starts in the extraocular and bulbar muscles, with associated autonomic features. Repetitive nerve stimulation usually shows an incremental muscle response. Treatment is supportive. The differential diagnosis is from naturally occurring paralysing illnesses such as Guillain–Barré syndrome, myasthenic crisis or diphtheria, from paralysing seafood neurotoxins (tetrodotoxin, saxitoxin), snake envenomation, and from chemical warfare poisoning by organophosphates.
Primary neurological infections are less feasible for use as bioweapons. There are theoretical possibilities of Venezuelan equine encephalitis transmission by inhalation and secondary zoonotic transmission cycles sustained by horses and mosquitoes. Severe haemorrhagic meningitis regularly occurs in anthrax, usually in the aftermath of severe systemic disease likely to have been transmitted by spore inhalation.
Panic and psychologically determined ‘me-too’ symptomatology are likely to pose the biggest diagnostic and management burden on neurologists handling bioterrorist attack on an institution or a random civilian population. Indeed civilian panic and disablement of institutional operations are likely to be prominent intentions of any bioterrorist attack.
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NATO. NATO handbook on the medical aspects of NBC defensive operations. AMedP-6(C) 2003; Part II – Biological.
- Botulinum toxin as a biological weapon: medical and public health management.JAMA. 2001; 285: 1059-1070
- Bioterrorism-related inhalational anthrax: the first 10 cases reported in the United States.Emerg Infect Dis. 2001; 7: 933-944
- PCR analysis of tissue samples from the 1979 Sverdlovsk anthrax victims: the presence of multiple Bacillus anthracis strains in different victims.Proc Natl Acad Sci U S A. 1998; 95: 1224-1229
- Bacillus anthracis on Gruinard Island.Nature. 1981; 294: 254-255
- Financial Times Magazine, 2004 (August 14): 13 Science matters.
- Bacterial toxins: a table of lethal amounts.Microbiol Rev. 1982; 46: 86-94
- Properties and use of botulinum toxin and other microbial neurotoxins in medicine.Microbiol Rev. 1992; 56: 80-99
- Experimental botulism in monkeys – a clinical pathological study.Exp Mol Pathol. 1967; 6: 84-95
- Systemic toxicity of botulinum toxin by intramuscular injection in the monkey.Mov Disord. 1988; 3: 333-335
- Crystal structure of botulinum neurotoxin type A and implications for toxicity.Nat Struct Biol. 1998; 5: 898-902
- Botulism in the United States: a clinical and epidemiologic review.Ann Intern Med. 1998; 129: 221-228
- Wound botulism in a patient with a tooth abscess: case report and review.Clin Infect Dis. 1993; 16: 635-639
- Epidemiologic, clinical and laboratory aspects of wound botulism.N Engl J Med. 1973; 289: 1005-1010
- Botulism in an adult associated with food-borne intestinal infection with Clostridium botulinum.N Engl J Med. 1986; 315: 239-241
- Botulism from inhalation.Med Klin. 1962; 57 ([in German]): 1735-1738
- Efficacy of prophylactic and therapeutic administration of antitoxin for inhalation botulism.in: DasGupta B.R. Botulinum and tetanus neurotoxins: neurotransmission and biomedical aspects. Plenum Press, New York1993: 473-476
- Biological warfare agents as threats to potable water.Environ Health Perspect. 1999; 107: 975-984
- Botulism type B: epidemiologic aspects of an extensive outbreak.Am J Epidemiol. 1978; 108: 150-156
- Iraq's biological weapons. The past as future?.JAMA. 1997; 278: 418-424
- Biohazard.Random House, New York1999
- Clinical features of types A and B food-borne botulism.Ann Intern Med. 1981; 95: 442-445
- Botulism in the United States, 1899–1973.Centers for Disease Control, Atlanta1978
- An electron microscopic study of the changes induced by botulinum toxin in the motor end-plates of slow and fast skeletal muscle fibres of the mouse.J Neurol Sci. 1971; 14: 47-60
- Sera from patients with motor neuron disease and associated paraproteinaemia fail to inhibit experimentally induced sprouting of motor nerve terminals.J Neurol Neurosurg Psychiatry. 1986; 49: 817-819
- Ultrastructural study of the motor end-plate in botulism and Lambert–Eaton myasthenic syndrome.J Neurol Sci. 1987; 81: 197-213
- The evolving field of biodefence: therapeutic developments and diagnostics.Nat Rev Drug Discov. 2005; 4: 281-297
- Experience with the use of an investigational F(ab′)2 heptavalent botulism immune globulin of equine origin during an outbreak of type E botulism in Egypt.Clin Infect Dis. 1996; 23: 337-340
- Equine antitoxin use and other factors that predict outcome in type A foodborne botulism.Am J Med. 1984; 76: 794-798
- Responses of airborne Clostridium botulinum toxin to certain atmospheric stresses.Technical Memorandum. vol. 62. US Army Biological Laboratories, Frederick (MD)1964
- Inhalation anthrax.Ann N Y Acad Sci. 1980; 353: 83-93
- Summary of notifiable diseases 1945–1994.MMWR Morb Mortal Wkly Rep. 1994; 43: 70-78
- Anthrax as a biological weapon: medical and public health management. Working Group on Civilian Biodefense.JAMA. 1999; 281: 1735-1745
- The Sverdlovsk anthrax outbreak of 1979.Science. 1994; 266: 1202-1208
- Bacillus anthracis meningitis.Neurology. 1975; 25: 525-530
- Anthrax meningitis. Report of two cases with autopsies.Acta Neuropathol. 1976; 36: 339-345
- Anthrax.N Engl J Med. 1999; 341: 815-826
- Fulminant meningitis due to Bacillus anthracis in 11-year-old girl during Ramadan.Lancet. 1996; 347: 828
- Pathology of inhalational anthrax in 42 cases from the Sverdlovsk outbreak of 1979.Proc Natl Acad Sci U S A. 1993; 90: 2291-2294
- Neurological aspects of biological and chemical terrorism: a review for neurologists.Arch Neurol. 2003; 60: 21-25
- Survival in anthrax meningitis.Pediatrics. 1972; 50: 329-333
- Anthrax vaccine: evidence for safety and efficacy against inhalational anthrax.JAMA. 1999; 282: 2104-2106
- Paralytic shellfish poisoning: a potential public health problem.Med J Aust. 2001; 175: 29-31
- Acute tetrodotoxin-induced neurotoxicity after ingestion of puffer fish.Ann Neurol. 2005; 57: 339-348
- Paralytic shellfish poisoning: clinical and electrophysiological observations.J Neurol. 1998; 245: 551-554
- Paralytic shellfish poisoning: post-mortem analysis of tissue and body fluid samples from human victims in the Patagonia fjords.Toxicon. 2004; 43: 149-158
- Puffer fish poisoning: a potentially life-threatening condition.Med J Aust. 2002; 177: 650-653
- Alphaviruses.in: Warrell D. Cox T. Firth J. Benz E. Oxford textbook of medicine. 4th ed. Oxford University Press, Oxford2003: 377-380
- Tick-borne encephalitis.Clin Infect Dis. 1999; 28: 882-890
- Diphtheritic polyneuropathy: a clinical study and comparison with Guillain–Barré syndrome.J Neurol Neurosurg Psychiatry. 1999; 67: 433-438
- Guillain–Barré syndrome.FA Davis Co, Philadelphia1991
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