Source: New England Journal of Medicine (MA)
Pubdate: Thu, 16 Jul 1998
Volume 339, Number 3


To the Editor:

Botulism causes skeletal-muscle weakness resulting from bacterial exotoxins
that irreversibly block the release of acetylcholine from presynaptic motor
neurons. We report three cases of botulism in members of the Native
American Church who consumed peyote, a cactus with hallucinogenic
properties that has been legalized for sacramental use in traditional
American Indian religious ceremonies.

Thirteen church members ingested peyote from a communal jar during a
ceremony. Two to four days afterward, three men (40, 42, and 72 years old)
noted the onset of bilaterally symmetric, moderate, flaccid weakness in all
extremities. Two had nasal speech, dysphagia, and diplopia. Two of the
patients consented to undergo electromyographic studies, the results of
which were notable for markedly diminished amplitudes of all compound
muscle action potentials, which increased greatly (40 to 82 percent) after
exercise. This magnitude of increase has been observed in 85 percent of
patients with botulism and indicates a presynaptic defect of the
neuromuscular junction, thus supporting the clinical diagnosis of botulism.

Field nurses from the Public Health Service recovered the peyote, which was
found to contain type B botulinum toxin in a bioassay in which the
administration of neutralizing antibodies prevented the paralytic death of
mice (Centers for Disease Control and Prevention, Botulism Laboratory,
Atlanta). Serum specimens from two patients were negative for the toxin, a
common finding when there is a delay in testing. The stool of one patient
contained a toxin that could not be typed. Ingestion histories were
unrevealing, and none of the freshly prepared food the patients consumed
could be recovered for testing. All three patients recovered within the
time expected for the production of new presynaptic terminals. One patient
required hospital observation and parenteral nutrition for 14 days, then
slowly recovered by 2 to 3 months; the second refused admission despite his
dysphagia but also recovered within the expected time frame; the third was
only mildly affected and recovered after 4 weeks. None required
antibotulinum toxin, which is reserved for patients whose condition
deteriorates seriously after ingestion of the botulinum toxin.

The ceremonial tea the patients had drunk was made from buttons of the
dried, alkaline-ground peyote cactus, which had been covered with water and
stored in a closed jar for two months under refrigeration. We believe that
this prolonged, nontraditional storage of unsterilized peyote produced an
anaerobic and alkaline environment that favored the growth and production
of toxin from spores of Clostridium botulinum that were probably on the
cactus. These cases of botulism from peyote illustrate that all ingested
substances, including herbal medications and religious sacraments, must be
considered as sources when botulism is suspected.

Hirofumi Hashimoto, M.D. Northern Navajo Medical Center Shiprock, NM
87420-9901 Victor J. Clyde Native American Church of Navajoland Lukachukai,
AZ 86507 Karen L. Parko, M.D. Northern Navajo Medical Center Shiprock, NM

posted by Daniel M. Perrine, Ph.D. Loyola College in Maryland Chemistry
Department, KH 468 4501 North Charles St. Baltimore, MD 21210-2699 voice:
410-617-2717 fax:  410-617-2803 email:   - ---
Checked-by: (Joel W. Johnson)