Introduction: Botulism is a neuroparalytic disorder caused by botulism toxin produced by Clostridium botulinum from foodborne exposure, wound contamination, or intestinal colonization. Botulism presents with bulbar weakness and descending paralysis. Early recognition is crucial for improving morbidity and mortality. We present a rare case of botulism secondary to consumption of spoiled food.
Description: A 68-year-old male with a past medical history of ischemic stroke and polysubstance abuse was transferred to our tertiary care center for evaluation of acute dysphagia and neuromuscular weakness. The patient was functionally independent prior to admission but was food insecure and had eaten spoiled food. He was intubated for NIF of -10, airway protection, and management of secretions. On initial exam, he was unable to open his eyes but otherwise alert, oriented, and engaged with yes/no questions (able to nod or use thumbs up). Pupils were equal and reactive to light, but visually sluggish. Further exam revealed complete ophthalmoplegia and absent corneal, cough, and gag reflexes. Neck flexion and extension were weak at 1/5 strength, upper extremities were 2/5 proximally and 4/5 distally, and lower extremities were 2/5 proximally and 5/5 distally. Sensation was diminished at bilateral feet but otherwise intact to all modalities. Reflexes were absent throughout, with no pathological reflexes seen.
The team promptly recognized that this could be botulism and was able to administer the antitoxin via the CDC. Unfortunately, the patient continued to decline with complete loss of cranial nerve function and worsened motor exam of the proximal upper extremities. The patient had a protracted course in the ICU with slow neurologic recovery and required tracheostomy and PEG tube placement. Prior to discharge, his exam was slightly improved with neck strength at 3/5 for both flexion and extension.
Discussion: Botulism is a life-threatening condition presenting with descending paralysis, absence of fever, and intact mental status. Recovery may take months as nerve pathways slowly regenerate. Food insecurity is not a traditional risk factor, as compared to consumption of honey or canned goods; however, as this case exhibits, botulism should be considered in a food-insecure patient with these clinical findings.
