The diagnosis of botulism should be considered in all patients with the acute onset of cholinergic dysfunction and muscle weakness. The pupils are usually dilated, paralysis of ocular and bulbar muscles invariably occurs along with weakness of limb and axial muscles. This diagnosis is supported by the presence of a neuromuscular block and confirmed by the detection of toxin. Although the clinical presentation in this patient supported this diagnosis and a neuromuscular defect was present, no botulinum toxin was found. Not until Clostridium botulinum, type B organisms were cultured was the diagnosis of "probable botulism" made in this patient. Myasthenia gravis, atypical Guillain-Barre syndrome and a brain stem vascular lesion were also considered in the differential diagnosis. The anoxic encephalopathy following the cardiorespiratory arrest was an additional complicating factor.
Aghdassi, Aziz and Teasdall, Robert D.
"Acute onset of bulbar and ocular paralysis: An isolated case, with differential diagnosis,"
Henry Ford Hospital Medical Journal
: Vol. 25
Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol25/iss2/8