A 53-Year-Old Social Media Worker With Dysphonia and Paresis

Paul P. Rega, MD


July 20, 2021


Tolosa-Hunt syndrome is a granulomatous inflammatory process near the cavernous sinus or within certain areas of the orbits. The disease manifests with one or more episodes of unilateral ocular pain in addition to paralysis of cranial nerves III, IV, and/or V. In contrast to this patient's presentation, there is typically no gastrointestinal prodrome or progression of the neurologic manifestations beyond the ocular nerves.

An association between SARS-CoV-2 infection and Guillain-Barré syndrome has been described in the recent literature.[1] Classically, Guillain-Barré syndrome is a demyelinating polyneuropathy associated with an acute ascending paralysis. Gastrointestinal symptoms, like what occurred in this patient, are not part of the prodrome in Guillain-Barré syndrome.

In North America, tick paralysis is common during the spring and summer when ticks are most active. Owing to the pandemic, this patient's activities have been primarily indoors rather than outdoors, where tick bites are more likely to occur. Furthermore, when this patient was undressed and placed in a gown in the ED, a tick would likely have been discovered. The neurologic manifestations occur while the tick is attached. Once the tick is removed, the paralysis resolves. The prodrome is an influenza-like illness, and acute abdominal pain is not a typical presentation. The second stage is an ascending paralysis, not a descending paralysis. Patients are ataxic and exhibit lower extremity muscular weakness.

Botulism is a neuromuscular disease caused by toxins generated by the anaerobic, Gram-positive bacterium Clostridium botulinum (Figure 3). Six syndromes are recognized: infant, foodborne, wound, adult colonization, inhalational, and iatrogenic. Of the eight neurotoxins (A to H), toxins A, B, and E (F, rarely) affect humans.[2,3] Type H was discovered in 1977.[4] These neurotoxins are considered the most potent biologic poison known.[2,3]

Figure 3.

From 2011 to 2015, 162 cases of botulism were reported annually (mean). Infant botulism, foodborne botulism, and wound botulism occurred in 71%-88%, 1%-20%, and 5%-10% of these cases, respectively.[3] For foodborne botulism, the incubation period from first exposure to symptom onset can be from 12 to 72 hours (range, 2 hours to 8 days). The classic manifestations begin with a symmetrical paresis or paralysis starting from head to toe. The initial symptoms of botulism poisoning include ptosis, dysphonia, dysphagia, dysarthria, xerostomia, and visual difficulties (ie, bulbar manifestations).[2,3]


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