Thread by @WuidQ

#IDgrandrounds
40M, late summer, +sudden R facial weakness, diplopia, dysphagia; later,+UE weakness; lives in Colorado, loves to hike, had a lot of tick bites.

What are your differential Dx?
@BradCutrellMD @Cortes_Penfield @DocWoc71 @Darcy_ID_doc @TxID_Edu @GermHunterMD

@BradCutrellMD @Cortes_Penfield @DocWoc71 @Darcy_ID_doc @TxID_Edu @GermHunterMD 1/10
CASE CONTINUED.

Stroke team activated upon ED arrival.

2 household members were rushed to the hospital for paralysis & respiratory compromise. Unfortunately, both died. All reported consuming home-canned food.

ID was called. CDC alerted & antitoxin flown in.

2/10
CASE RESOLUTION: Foodborne botulism

@Cortes_Penfield @TxID_Edu @BradCutrellMD & @JIOReilly highlighted the important DDx for this case.

Many ID Dx can p/w various neuro ssx depending on the direct/indirect involvement of the central/peripheral nervous system

3/10
ID illness script for patient w/ extremity weakness +/- cranial nerve involvement should also consider, among many things:

✔️Paralysis progression

▪️ Ascending paralsysis (extremities 1st ▶️ CN's later)

👉 GBS
👉 WNV
👉 Tick paralysis
👉 Most causes of flaccid paralysis

4/10
▪️ Descending paralysis (early CN involvement ▶️ extremities, like in this case)

👉BOTULISM is the 🌟classic example (most common at onset: diplopia, dysphagia, blurred vision, facial weakness, ptosis)
👉Diphtheric polyneuropathy (exceedingly rare; can be ascending too)

5/10
✔️ +/- Fever

▪️ No fever: GBS, tick paralysis, botulism, some viral causes of flaccid paralysis

▪️ Usually with fever: WNV

6/10
✔️Sensory involvement:

▪️ + involvement: GBS (usually)
▪️ No involvement (to mildly +): WNV, tick paralysis, botulism

✔️Mental status

▪️ Intact: GBS, botulism, tick paralysis
▪️ +change: WNV (depending on +/- encephalitis)

7/10
Many other things to consider in the illness script especially if you want to entertain non-ID Dx:

✔️Deep tendon reflexes, NCV/EMG, CSF findings.

A good review here: academic.oup.com/epirev/article…

8/10
‼️ Botulism can rapidly progress from mild illness to fulminant disease that can end in death within 24 hours.

Case highlights the importance of EARLY recognition of botulism:
✔️Descending paralysis w/ early CN involvement
✔️No fever, intact mental status, no sensory change

9/10
Once suspected, check state requirements and notify early.

Botulism is Category I (A) state reportable disease. Must be immediately reported by phone, fax, rapid communication upon ✔️1st knowledge OR ✔️ suspected.

Also category A bioterrorism agent.

10/10
For further review, botulism was covered previously at WuidQ:

(1)

https://twitter.com/WuidQ/status/1033049390942969858?s=20

(2)

https://twitter.com/WuidQ/status/1063557486089629696?s=20

Many thanks again to our brilliant fellow @LauraMarks5 for presenting the case and highlighting important points about botulism! #Idmeded