Guideline sources The following summarized guidelines for the evaluation and management of botulism are prepared by our editorial team based on guidelines from the Center for Disease Control (CDC 2021). 1 Guidelines 1. Screening and diagnosis Differential diagnosis: suspect botulism in patients with suspected myasthenia gravis or Guillain- Barr syndrome and in patients with unexplained symmetric cranial nerve palsies, with or without paresis of other muscles. E 2. Diagnostic investigations History and physical examination: Elicit history of possible exposures to well-described sources of botulinum toxin, while keeping in mind that the absence of such exposures does not exclude the possibility of botulism. E https://web.pathway.md/diseases/rec7U2yB1IZOUVnV7 1/4 6/29/23, 3:20 AM Botulism Pathway Perform thorough, serial neurologic examinations to detect neurologic deficits of botulism and assess their progression. E Laboratory testing: discuss specimen collection with the expert consultant from the local or state health department. E Show 2 more Electrodiagnostic studies: consider obtaining electrodiagnostic studies (such as repetitive nerve stimulation, EMG, and nerve conduction studies) when feasible to assist in the diagnosis of suspected botulism. E 3. Medical management Contacting local or state health department: contact the local or state health department's emergency on-call staff immediately when botulism is suspected to arrange an emergency expert clinical consultation and, when indicated, request botulinum antitoxin. E Antitoxin therapy: administer botulinum antitoxin in patients with suspected botulism as early as possible in the course of illness, recognizing that the greatest benefit accrues within the first 2 days of illness onset. Administer botulinum antitoxin in symptomatic patients with suspected botulism on the basis of clinical findings. Do not await laboratory confirmation because results might take several days, and they can be negative in patients with botulism. E Show 6 more Other agents: administer aminoglycosides, magnesium, clindamycin, tetracycline, or calcium in patients with botulism only after careful consideration and with appropriate monitoring. E Supportive care: provide meticulous attention to bladder and bowel care and the prevention of complications, such as UTIs, deep vein thrombosis, and pressure ulcers. E Show 5 more 4. Inpatient care Serial clinical assessment (neurologic deficits): obtain frequent, serial neurologic examinations with an emphasis on cranial nerve palsies, swallowing ability, respiratory status, and extremity strength. Conduct the serial neurologic and other examinations by the same healthcare provider, when possible. E Show 2 more Serial clinical assessment (respiratory compromise): obtain frequent, serial monitoring of respiratory function in patients with botulism. Adjust the frequency of examinations on the basis of signs and symptoms, with very frequent examinations in patients with rapid progression and in patients with respiratory symptoms not required intubation. E Show 3 more Serial clinical assessment (hemodynamic status): Obtain continuous monitoring of cardiac rhythm and frequent measurements of BP. E https://web.pathway.md/diseases/rec7U2yB1IZOUVnV7 2/4 6/29/23, 3:20 AM Botulism Pathway Obtain frequent monitoring for urinary retention. E Serial clinical assessment (other complications): obtain frequent monitoring for constipation or ileus, dry mouth, and dry eyes. E 5. Specific circumstances Pediatric patients: Obtain close monitoring for worsening paralysis in pediatric patients with suspected foodborne botulism treated with botulinum antitoxin therapy according to the weight-based dose described in the package insert. E Consider administering retreatment in patients with a lack of response to the treatment when confidence in the diagnosis of botulism is substantial. E Pregnant patients: administer botulinum antitoxin therapy in pregnant patients with suspected foodborne botulism in the same manner as nonpregnant patients. E Show 3 more Clinical findings Symptoms Past events Abdominal pain Ingestion of home-canned food Blurry vision Ingestion of honey Constipation Ingestion of improperly preserved food Difficulty speaking Diplopia Vital signs Dry eyes Dry mouth Bradycardia Dysarthria Hypotension Dysphagia Tachycardia Facial weakness Respiratory exam Muscle weakness Nausea Respiratory distress Poor feeding Shortness of breath Vomiting Social history IV drug use Nasal cocaine use Neurological exam https://web.pathway.md/diseases/rec7U2yB1IZOUVnV7 3/4 6/29/23, 3:20 AM Botulism Pathway Ataxia Cranial nerve palsy Descending flaccid paralysis Hyporeflexia Mydriasis Ophthalmoplegia Paralysis References 1. Agam K Rao, Jeremy Sobel, Kevin Chatham-Stephens et al. Clinical Guidelines for Diagnosis and Treatment of Botulism, 2021. MMWR Recomm Rep. 2021 May 7;70 2 1 30. Open https://web.pathway.md/diseases/rec7U2yB1IZOUVnV7 4/4