Morning report 7/20/17

Morning report 7/20/17

37 year-old male who, 48 hours after a GI illness, developed fixed, dilated pupils, dysphagia, and bilateral ptosis, with progression to neuromuscular hypercapnic respiratory failure.

Diagnosis: foodborne botulism.

Teaching points:

  • Botulism toxin blocks Ach release at presynaptic neurons and at the NMJ = motor and endocrine symptoms
  • Foodborne botslism presents with:
    1. GI prodrome à 12-36 hours à sore throat (salivation blocked) and 4 Ds of bulbar palsy (diplopia, dysphagia, dysarthria, dysphonia) à descending paralysis
    2. No fever, normal vitals, normal mental status
    3. No sensory deficits, aside from blurry vision (pupillary constrictor paralysis, dry eye (lacrimation blocked), or CNIII involvement).

 

Diagnosis Hallmarks Why this diagnosis does not fit with the patient’s presentation
Myasthenia Gravis Bulbar palsy, ptosis Weakness is fatigable.

Treating with an acetycholinesterase inhibitor would have NO EFFECT in botulism (Ach never released).

Miller-Fisher variant of Guillan Barre Complete opthalmoplegia, ataxia, areflexia, followed by extremity weakness Ataxia, +anti-GQ1B antibodies.

IVIG and plasmapheresis will have no effect in botulism.

Classic Guillan Barre Ascending weakness after GI illness Ascending weakness
MS Bulbar palsy, INO Usually female. Sensory and cerebellar symptoms. Optic neuritis.
Organophosphate poisoning DUMBELS Acetylcholine excess

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