Abdominal Pain, Dyspnea, and Diplopia

Posted by • January 27th, 2015

Peripheral causes of acute generalized weakness include motor neuronopathies, acute acquired polyneuropathies, myopathies, and presynaptic and postsynaptic neuromuscular-transmission disorders.

Clinical Pearls

– Is botulism a presynaptic or postsynaptic neuromuscular-transmission disorder?

Botulism is a toxin-mediated disease that results in the presynaptic blockade of acetylcholine transmission across the neuromuscular junction. 

– What is adult intestinal toxemia?

Adult intestinal toxemia is a rare form of botulism that is caused by colonization of the gut by toxigenic clostridium bacteria. In adult intestinal toxemia, C. baratii is more frequently the pathogen than C. botulinum.

Morning Report Questions

Q: What are the clinical features of botulism? 

A: Patients typically present with blurred vision, ptosis, and diplopia. Impaired bulbar function is manifested as facial weakness, dysarthria, and dysphagia. Descending muscle weakness affects head control and subsequently arm, respiratory, and leg musculature. The weakness typically has a proximal-to-distal pattern and is bilateral. Autonomic symptoms, including nausea, vomiting, ileus, poor pupil reactivity, and alterations in blood pressure and heart rate, are common; the gastrointestinal symptoms may precede the neurologic symptoms. Intact sensorium, preserved sensation, and absence of fever are typical. Results of cerebrospinal fluid, blood, and urine tests and imaging studies are usually normal.

Q: How is botulism managed?  

A: The mainstays of botulism management are rapid clinical recognition and notification of public health authorities, which enables the prompt investigation of the toxin source and possible other cases and the prompt delivery and administration of antitoxin. The effectiveness of antitoxin is greatest if it is given early after the onset of neurologic symptoms, ideally within 24 hours, and thus antitoxin should be administered, after consultation with public health authorities, on the basis of the clinical diagnosis and without awaiting the results of diagnostic testing. Antibiotic therapy has not been shown to improve neurologic recovery and is not recommended. There is no person-to-person transmission of botulism, and in the health care setting, patients can be treated with standard precautions.     

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