Today’s pearl is courtesy of North Korea. They claimed that Otto Warmbier, an imprisoned American who unfortunately died a few days after his return to the US, had suffered brain damage after contracting botulism. If you think that sounds wonky, you’re probably right. If you thinks that sounds probable, here is a refresher on botulism, a rare but deadly disease.


Anaerobic Clostridium botulinum produces an endotoxin that inhibits ACh release, resulting in neuromuscular paralysis; untreated can lead to respiratory failure. The spores can be found in soil, and are heat resistant.


(OK, I don’t want to agree with NK, but I suppose theoretically he could have had anoxic brain injury from botulism induced acute resp failure. I’m no federal agent [or am I?], but I think it is more probable that they accidentally overdosed him.)


There are multiple ways to acquire botulism:

  • Foodborne – ingest preformed toxin; home canned products
  • Wound – toxin produced by C botulinum once it infects the wound (mostly IVDU)
  • Infant – ingest spores that then produce toxin; affects ages 1 week – 11 months; honey
  • Adult enteric – similar to infant’s (ingest the spore that then goes on to make the toxin in vivo)
  • Iatrogenic – due to botox injections
  • Inhalation – aerosolized as act of bioterrorism
    • Characterized as a category A bioweapon (the most lethal) by the CDC


Symptom onset: 6-48 hours s/p toxin poisoning

  • Foodborne and enteric: GI upset
  • Descending symmetric paralysis
  • Starts with cranial nerves – diplopia, blurred vision, dysarthria
  • Anticholinergic symptoms
  • Pupils dilated and nonreactive (how to differentiate from MG)
  • Infants – “floppy” baby; lethargic, weak, constipated


Diagnosis is made clinically; exclude other conditions (ie, LP to r/o GBS).

Assay not commonly available; can ID toxin in serum or stool.

Food source can also be tested for toxin.



  • Botulinum equine antitoxin effective when used early; decreases days on vent
  • Human botulism immunoglobuin decreases vent requirements and ICU stay
  • Supportive. Intubation if respiratory failure. 
  • Report to health department



Look who wrote this Tintinalli topic –

Andrus, Phillip, and J. Michael Guthrie. “Acute Peripheral Neurologic Disorders.” Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e Eds. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2016,

May 2024