Botulism: “I don’t need to talk, but I do need to swallow!”

Abstract

Botulism is a rare, toxin-mediated neurological illness characterized by acute descending flaccid paralysis affecting motor and autonomic function without sensory involvement. Common initial presenting symptoms in adults include the “four D’s” (diplopia, dysarthria, dysphagia, dry mouth). Cranial nerve paralysis can lead to difficulty swallowing and handling secretions. Ultimately, motor paralysis can lead to respiratory failure and the need for mechanical ventilation. Infants and children may present with more subtle features, especially in the very young patient who may only present with constipation or difficulty feeding. As noted, clusters can arise in conjunction with foodborne outbreaks; hence, a high clinical suspicion is needed when multiple individuals are affected. Diagnosis is presumptive while awaiting definitive toxin assay results, though often times, the assay may be negative regardless. EMG may also be helpful. In the meantime, however, attention needs to be given to identification of airway compromise from bulbar dysfunction/paralysis and respiratory fatigue requiring mechanical ventilation.