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Type B botulism

A 41-year-old man was admitted to General Rose Memorial Hospital because of difficulty swallowing. On the morning of the day prior to admission, he developed nasal speech, and later that day he noted difficulty swallowing. On admission, he was awake, alert, and oriented. Cranial nerve examination revealed no gross abnormality of extraocular movements or pupillary responses, but the patient did complain of diplopia on left lateral gaze. He had absent gag reflexes, very poor tongue movements, and much difficulty with his secretions. Motor examination revealed bilaterally symmetrical proximal weakness in the upper limbs with mild distal weakness. Strength in the lower extremities appeared to be normal. The deep tendon reflexes were normal and symmetrical. Plantar responses were flexor. Sensory examination was within normal limits. An edrophonium ( Tensilona) test performed shortly after admission was negative. Lumbar puncture was performed and was normal. Subsequent spinal fluid studies were also normal. On the evening of admission, a tracheostomy was performed. A program of intensive medical care including respiratory care was instituted. Serum from the patient was sent on the day of admission to the National Communicable Disease Center in Atlanta. This serum proved to be positive for type B botulinum toxin. He was treated with bivalent antitoxin (Lederle type AB) in the first four days, receiving a total dose of 120,000 units. He was also treated with guanidine hydtochloride and intravenous calcium. His disease progressed over the next five days, and he developed the following signs: a total ophthalmoplegia including bilateral ptosis, bilateral facial palsies, inability to move the tongue, more profound upper extremity paresis, and weakness of both lower extremities which progressed to paralysis by the end of the fifth day. The patient experienced increased pulmonary problems. These necessitated the use of mechanical respirators, at first intermittently and then continuously. He developed fever of 102" F., and after appropriate cultures were taken, he was treated with antibiotics. He had continuous monitoring of his blood gases, blood counts, chemistries, and ECGs. Because of the fear of possible pulmonary emboli, the patient was treated with anticoagulants. On the seventh hospital day, his fever rose to 105" F. Anticoagulants were discontinued. Six hours later, the patient had a sudden cardiac arrest but was resuscitated. Following the arrest, he had massive gastrointestinal bleeding and required transfusions. He remained in a comatose state until his death six days later. The major findings on postmortem examination were pneumonia, perforated duodenal ulcer with retroperitoneal abscess, infarction of posterior yapillary muscle, and pancreatitis. Postmortem b ood cultures were positive for Escherichia coli.