Snapshot A 30-year-old woman presents to the emergency room for blurry vision. She reports that she had been watching a movie when she started seeing double and had difficulty swallowing her popcorn. She recently visited a farm, where she bought and consumed numerous pickles, jams, and cheeses. She states that her arms and face also feel weak. On physical exam, she has symmetric facial weakness, with drooping eyelids. She also has bilateral arm weakness, with loss of deep tendon reflexes. Presentation Symptoms gastrointestinal upset in foodborne botulism Physical exam cranial nerve palsies blurry vision ptosis facial weakness drooping eyelids 4 D’s Diplopia Dysarthria Dysphagia Dyspnea autonomic nervous system dysfunction dry mouth postural hypotension descending symmetric muscle weakness and flaccid paralysis absent deep tendon reflexes Studies Labs typically normal toxin may be detected from serum, stool, or wound process takes a few days, so this is only used as confirmatory testing Making the diagnosis most cases are clinically diagnosed Differential Guillain-Barré syndrome distinguishing factor typically an ascending paralysis Treatment Management approach immediate treatment with antitoxin Medical equine-derived heptavalent antitoxin indication patients > 1 years of age Complications Respiratory paralysis Permanent paralysis