eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Botulism: Differential Diagnoses & Workup

Author: Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Coauthor(s): Daniel AC Frattarelli, MD, FAAP, Senior Staff, Departments of Pediatrics and Emergency Medicine, Henry Ford Hospital; Nahed M Abdel-Haq, MD, Assistant Professor, Department of Pediatrics, Wayne State University School of Medicine
Contributor Information and Disclosures

Updated: Jan 21, 2009

Differential Diagnoses

Dehydration
Hypermagnesemia
Hypothyroidism
Poliomyelitis
Toxicity, Carbon Monoxide
Toxicity, Organophosphates

Other Problems to Be Considered

Guillain-Barré syndrome (especially Miller-Fisher variant)
Acute poliomyelitis
Myasthenia gravis
Lambert-Eaton syndrome
Tick paralysis
Stroke
Aminoglycoside toxicity
Atropine poisoning
Paralytic shellfish poisoning (saxitoxin)
Puffer fish ingestion (tetrodotoxin)
Sepsis
Meningitis/encephalitis
Congenital myopathy
Electrolyte imbalance
Genetic metabolic disorders

Workup

Laboratory Studies

Although clinical suspicion should be sufficient to prompt supportive therapy for botulism, other differential diagnoses must be excluded.

  • Obtain stool cultures in all patients, adding wound cultures if wound botulism is suspected.
  • Approximately 60% of food-borne cases yield positive culture results; a positive finding in the presence of flaccid paralysis is diagnostic. Currently, specific assays for the toxin, including enzyme-linked immunoassays and polymerase chain reaction, are under investigation.
  • Currently, the mouse inoculation test is the best test available and can be performed by the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia. In the assay, mice are injected with a serum sample from the patient and test results are considered positive for toxin if the mice die of respiratory arrest within 24 hours. The exact type of toxin is determined through pretreating each mouse in a set of mice with a different type-specific antitoxin, then injecting the serum. The mouse left alive the next day is the one pretreated with the antitoxin to the toxin affecting the patient.

Imaging Studies

  • Perform CT scanning or MRI as clinically indicated to exclude stroke.

Other Tests

  • Perform an edrophonium chloride test to exclude myasthenia gravis, if indicated, although transient responses have been reported with botulism.
  • Electromyelography (EMG) demonstrates a nonspecific, decreased amplitude of action potentials. Rapid repetitive EMG at frequencies of 20-50 Hz is more specific for botulism and useful in excluding Guillain-Barré syndrome, but this response does not distinguish botulism from Lambert-Eaton syndrome. Infant botulism is characterized by a pattern known as brief, small, abundant motor-unit action potential on EMG in clinically affected muscles.

Procedures

  • Lumbar puncture findings can usually exclude Guillain-Barré syndrome, a condition that tends to elicit a higher protein level in cerebrospinal fluid (especially later in the course of the disease) than does botulism.

More on Botulism

Overview: Botulism
Differential Diagnoses & Workup: Botulism
Treatment & Medication: Botulism
Follow-up: Botulism
Multimedia: Botulism
References
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Further Reading

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Keywords

botulism, constipation, food poisoning, dry mouth, autonomic dysfunction, Bacillus botulinus, blurred vision, botulinum toxin, botulinus, botulism, Clostridium argentinense, C argentinense, Clostridium baratii, C baratii, Clostridium botulinum, C botulinum, Clostridium butyricum, C butyricum, decreased ocular motility, diplopia, dysarthria, dysphagia, food-borne botulism, hyporeflexia, hypotonia, infant botulism, muscle weakness, mydriasis, orthostatic hypotension, paralysis, ptosis, urinary retention, wound botulism, abdominal cramps

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Contributor Information and Disclosures

Author

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Consulting; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching; sanofi pasteur Grant/research funds Unrestricted research grant; sanofi pasteur  Consulting; sanofi pasteur Honoraria Speaking and teaching; Tap Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Coauthor(s)

Daniel AC Frattarelli, MD, FAAP, Senior Staff, Departments of Pediatrics and Emergency Medicine, Henry Ford Hospital
Daniel AC Frattarelli, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Clinical Pharmacology, and American Society for Clinical Pharmacology and Therapeutics
Disclosure: Nothing to disclose.

Nahed M Abdel-Haq, MD, Assistant Professor, Department of Pediatrics, Wayne State University School of Medicine
Nahed M Abdel-Haq, MD is a member of the following medical societies: American Academy of Pediatrics, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Medical Editor

Itzhak Brook, MD, MSc, Professor, Department of Pediatrics, Georgetown University School of Medicine
Itzhak Brook, MD, MSc is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Armed Forces Infectious Diseases Society, Association of Military Surgeons of the US, Infectious Diseases Society of America, International Immunocompromised Host Society, International Society for Infectious Diseases, Medical Society of the District of Columbia, New York Academy of Sciences, Pediatric Infectious Diseases Society, Society for Ear, Nose and Throat Advances in Children, Society for Experimental Biology and Medicine, Society for Pediatric Research, Southern Medical Association, and Surgical Infection Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Leslie L Barton, MD, Professor, Program Director, Department of Pediatrics, University of Arizona School of Medicine
Leslie L Barton, MD is a member of the following medical societies: American Academy of Pediatrics, Association of Pediatric Program Directors, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting; Pfizer Honoraria Consulting

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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