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 | | Diagnosis | |
- Use history to elicit neurologic symptoms and details of exposure compatible with botulinum toxin poisoning.
- Consider cranial nerve abnormalities as key findings in the diagnosis of botulinum toxin poisoning.
- Collect body fluid samples quickly to confirm the diagnosis of botulinum toxin poisoning.
- Consider obtaining nerve conduction studies to confirm botulinum toxin poisoning but do not delay treatment to obtain this test.
- Consider performing other studies if the clinical picture is confusing.
- Consider other more common causes of bulbar weakness in the differential diagnosis of botulinum toxin poisoning.
| | History and Physical Examination Elements for Adult Botulinum Toxin Poisoning (table)
| | Laboratory and Other Studies for Botulinum Toxin Poisoning (table)
| | Differential Diagnosis of Botulinum Toxin Poisoning (table)
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Use history to elicit neurologic symptoms and details of exposure compatible with botulinum toxin poisoning.  |
- Ask about:
- Acute onset of the four Ds: disturbed vision, dysphagia, dysphonia, and descending bilateral weakness
- Abdominal cramps, nausea, and diarrhea (early in the course of foodborne illness)
- Constipation if neurologic symptoms are present
- Exposure to homemade or poorly prepared commercial food items in the past 2 weeks
- Open wounds or evidence of skin popping on arms or legs
- History of drug abuse predisposing to wound botulism
- Recent travel to more arid endemic areas where the soil may be contaminated
- Previous gastrointestinal surgery, irritable bowel disease, or recent systemic antibiotics, which may predispose adults to enteric colonization with C. botulinum or C. baratii
- Medication use, such as aminoglycoside antibiotics
- Exposure to toxins, such as organophosphate
- Recent illness that may suggest another disorder, such as Guillain-Barré disease
- Recent exposure to ticks, which may suggest Lyme disease or tick paralysis
- A history of myasthenia gravis or fluctuating weakness, diplopia, and ptosis during the day
- In infants, ask parent about:
- Use of honey or corn syrup
- Constipation
- Irritability
- Lethargy
- Poor feeding
- Bulbar palsy (such as poor suck)
- Head weakness
- See table History and Physical Examination Elements for Adult Botulinum Toxin Poisoning.
- See table History and Physical Examination Elements for Infant Botulinum Toxin Poisoning.
- See table Clinical Presentations of Different Types of Botulism.
| Background | Back to top
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Consider cranial nerve abnormalities as key findings in the diagnosis of botulinum toxin poisoning.  |
| Background | Back to top
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Collect body fluid samples quickly to confirm the diagnosis of botulinum toxin poisoning. |
- Consult the CDC laboratory immediately for advice on collection of samples.
- Obtain samples of serum, stool (collected with sterile water), gastric fluid, vomitus, and suspected food to test for toxin with the mouse bioassay.
- Obtain samples before treatment with antitoxin.
- Refrigerate all samples.
- Provide the laboratory with a list of the patient's medications.
- See table Laboratory and Other Studies for Botulinum Toxin Poisoning.
| Background | Back to top
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Consider obtaining nerve conduction studies to confirm botulinum toxin poisoning but do not delay treatment to obtain this test. |
- Obtain nerve conduction testing of the most affected body part, usually the face or upper neck area.
- In ordering nerve conduction studies, specifically ask that the neurophysiology laboratory evaluate the neuromuscular junction by looking for a marked increase in the size of the response after repetitive stimulation with 30 to 50 Hz or exercise, or for an increase in jitter by single-fiber EMG.
- See table Laboratory and Other Studies for Botulinum Toxin Poisoning.
| Background | Back to top
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Consider performing other studies if the clinical picture is confusing. |
- In patients presenting acutely with cranial nerve signs, consider obtaining:
- Imaging studies such as MRI with diffusion-weighted imaging to exclude stroke and MRI with gadolinium to look for basilar meningitis
- Lumbar puncture with CSF analysis for CNS infections
- Lumbar puncture to look for elevated CSF protein associated with Guillain-Barré syndrome
- See table Laboratory and Other Studies for Botulinum Toxin Poisoning.
| Background | Back to top
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Consider other more common causes of bulbar weakness in the differential diagnosis of botulinum toxin poisoning. |
- Consider conditions that mimic botulinum toxin poisoning, including:
- Guillain-Barré syndrome, particularly the Miller-Fisher variant (eyes only)
- Myasthenia gravis
- Lambert-Eaton syndrome
- Tick paralysis (similar picture to Guillain-Barré but with paresthesia)
- Poliomyelitis
- CNS infections, stroke, or tumor
- Psychiatric symptoms masquerading as dysphonia
- Viral syndrome with complaints of generalized weakness
- Inflammatory myopathy
- Toxic exposure to pyridostigmine, ethanol, organophosphates, carbon monoxide, nerve gas, methanol, barium carbonate, methyl chloride, atropine, mushroom poisoning, paralytic shellfish poisoning, hypermagnesemia, and aminoglycoside antibiotics
- In infants, consider simple constipation, Hirschsprung's disease, and motor neuron disease (Werdnig-Hoffman syndrome), metabolic disorders (glutaric aciduria type 1, maple syrup urine disease, Leigh's syndrome, succinic semialdehyde dehydrogenase deficiency, mitochondrial disorders), cerebral atrophy secondary to in utero drug exposure, cerebral infarctions, spinal epidural hematoma, spinal muscular atrophy type 1, and enterovirus encephalitis.
- See table Differential Diagnosis of Botulinum Toxin Poisoning.
| Background | Back to top
| | | FAQs |
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| The American College of Physicians is accredited by the Accreditation Council for continuing Medical Education (ACCME) to provide continuing education for physicians. The American College of Physicians designates this enduring material for a maximum of 1 AMA PRA Category 1 Credit. Physicians should claim only credit commensurate with the extent of their participation in the activity. Purpose: This activity has been developed for internists to facilitate the highest quality professional work in clinical applications, teaching, consultation, or research. Upon completion of the CME activity, participants should be able to demonstrate an increase in the skills and knowledge required to maintain competence, strengthen their habits of critical inquiry and balanced judgement, and to contribute to better patient care. Disclosures: Larry E. Davis, MD, FACN, FACP received honorarium from Merck & Co., provided expert testimony, received grants from the VA, NIH, and the University of New Mexico, received royalties from Fundamentals of Neurologic Disease. Deborah Korenstein, MD, FACP, Co-Editor, PIER, has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Richard B. Lynn, MD, FACP, Co-Editor, PIER, has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. |
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Botulinum Toxin Poisoning
