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

Paul P. Rega, MD


July 20, 2021

The patient in this case received the botulinum antitoxin, and her clinical manifestations resolved almost completely within 24 hours. She did not need intubation or mechanical ventilation support.

Any patient with a presumptive diagnosis of botulism may require invasive airway management, owing to impending paralysis. Patients who may have a difficult airway should be identified early. Such patients include those who have short necks, obvious nuchal and/or facial abnormalities, or disconcerting results on an airway assessment tool (eg, the Mallampati score). For this type of patient, an elective intubation is safer than an emergency intubation.

Another situation that must be planned for is a community-wide outbreak with limited healthcare resources. Between 1977 and 2015, there were six foodborne botulism outbreaks involving multiple patients. The smallest outbreak (16 people) occurred in Texas in 2001 and was caused by contaminated chili at a church function. The highest caseload was 58 patients in Michigan in 1977. In this outbreak, home-canned peppers served at a local restaurant contained the botulinum toxin (Figure 4).[12]

Figure 4.

As patients involved in an outbreak arrive at an ED, there may be a paucity of respiratory therapists and equipment to evaluate progressive respiratory failure expediently. One solution is the single-breath counting test.[15] Its functionality is not limited by skill set, equipment needs, or geography. The next step is to triage certain patients to outlying institutions to avoid compromising healthcare capabilities at the initial hospital. Reverse triage may be the safest method; that is, transporting the intubated patients whose condition is less likely to deteriorate en route.

Botulism is a complicated disease for both patients and their communities. It must be managed with equal measures of skill and flexibility.


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