Rare presentation of botulism with generalized fasciculations
A 35-year-old male, presented with complaints of sudden onset pain abdomen of 8 hours duration following consumption of stale food (fried gram flour in buttermilk; Dahi Vada (Indian snack) kept inside a container since 4 days). He had one episode of vomiting; however there was no complaint of diarrhea. On 2nd day, he developed acute onset bilateral symmetrical drooping of eyelids with blurring of vision and difficulty in swallowing along with hoarseness of voice and dryness of mouth. He gradually developed progressive weakness of both upper limbs followed by lower limbs, with associated involuntary generalized twitching movements involving entire body. There were no complaints of seizures, altered sensorium, sensory symptoms, and bladder involvement. There was no history of medication intake, insect bite, or snake bite.\nOn admission, he was conscious and oriented. Vitals were stable with pulse rate of 68/min and blood pressure was 130/80 mmHg without postural fall. He was afebrile with mild tachypnea. Single breath count was 26. Higher mental functions were normal. Cranial nerve examination revealed bilateral dilated sluggishly reactive pupils, bilateral symmetrical ptosis with complete ophthalmoplegia along with decreased gag reflex. Motor system examination showed normal tone with bilateral symmetrical quadriparesis (muscle power, Medical Research Council (MRC) grade 4-/5). Deep tendon reflexes were normally elicitable with bilateral flexor plantar response. Patient also had generalized fasciculations involving anterior chest wall and bilateral upper and lower limbs []. Sensory and cerebellar system examination was normal. There were no signs of meningeal irritation.\nIn view of history of symptom onset following stale food intake with presentation of dry mouth, bilateral ptosis with ophthalmoplegia, bulbar weakness, and lower motor neuron (LMN) quadriparesis, with normal deep tendon reflexes, possibility of neuromuscular junction affection; most likely food borne botulism was kept.\nHematological evaluation revealed hemoglobin (Hb)-14.8 gm%, total leukocyte count - 10,500/mm3, platelets-1.71 lakh/mm3, and erythrocyte sedimentation rate (ESR)-25 mm/1 h. Biochemical parameters showed fasting blood sugar-74 mg/dl, urea-35 mg/dl, serum (S.) creatinine-0.9 mg/dl, S. sodium-136 meq/l, S. potassium-4.5 meq/l, S. calcium-9.2 mg/dl, S. magnesium-2.0 mg/dl, and serum creatine phosphokinase (CPK)-793 IU/l. Liver function tests were mildly deranged with serum glutamic oxaloacetic transaminase (SGOT)-95 IU and serum glutamic-pyruvic transaminase (SGPT)-66 IU. Thyroid profile was normal. Electrocardiogram, chest X-ray, and ultrasonography (USG) abdomen were normal. HIV ELISA was negative. Stool culture was sent.\nNoncontrast computerized tomography of head with thin brainstem sections was normal. Motor and sensory nerve conduction study was suggestive of pure motor axonal affection of both upper and lower limbs with normal distal latency and conduction velocities. Three hertz repetitive nerve stimulation (RNS) test was negative for decremental response. High frequency (50 Hz) RNS also did not show any incremental response. Parenteral neostigmine test was negative.\nPatient was managed conservatively keeping in view the possibility of foodborne botulism presenting as features of neuromuscular blockade. He was treated with cathartics, intravenous antibiotics, and short course of intravenous steroids (hydrocortisone). Respiratory and hemodynamic parameters were closely monitored. Patient showed gradual improvement of ptosis, ophthalmoplegia, limb weakness, and dysphagia. Respiratory effort improved and fasciculations subsided []. Repeat biochemical and hematological parameters were normal. Stool culture was sterile. He was discharged after 2 weeks.