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Last reviewed: 1 Nov 2023
Last updated: 01 Oct 2021



History and exam

Key diagnostic factors

  • ingestion of contaminated foods
  • infant age group
  • biologic terrorism
  • blurred vision and diplopia
  • impaired accommodation
  • ptosis
  • oculobulbar weakness
  • hypoglossal weakness
  • dysarthria
  • dysphagia
  • symmetrical descending flaccid paralysis
More key diagnostic factors

Other diagnostic factors

  • hypotonia
  • weakened cry in infants
  • feeding difficulties in infants
  • postural hypotension
  • hypothermia
  • urinary retention
  • constipation
  • dry mouth and throat
  • gastrointestinal illness
  • diminished or absent deep tendon reflexes
  • absence of fever
  • respiratory dysfunction
  • pupillary dilation
Other diagnostic factors

Risk factors

  • ingestion of contaminated foods
  • ingestion of honey in infants
  • ingestion of soil in infants
  • intravenous drug use
  • crush injury
  • infant age group
  • abnormal bowel anatomy
  • therapeutic or cosmetic use of botulinum toxin
  • biologic terrorism
  • exposure to reptiles
More risk factors

Diagnostic investigations

1st investigations to order

  • mouse bioassay of serum, gastric secretions, stool, or food samples
  • culture of food samples, gastric aspirates, or fecal material
More 1st investigations to order

Investigations to consider

  • electrophysiologic testing
More investigations to consider

Emerging tests

  • enzyme-linked immunosorbent assay (ELISA)
  • polymerase chain reaction (PCR)

Treatment algorithm


foodborne botulism

wound botulism

iatrogenic botulism

inhalational botulism (biological attack)



Linda S. Nield, MD, FAAP
Linda S. Nield

Professor of Pediatrics and Medical Education

West Virginia University School of Medicine




LSN is an author of a reference cited in this topic.


Dr Linda S. Nield would like to gratefully acknowledge Dr Thomas P. Bleck, Dr Aimee Hodowanec, Dr Pavani Reddy, and Dr Teresa Zembower, previous contributors to this topic.


TPB, AH, PR, and TZ declare that they have no competing interests.

Peer reviewers

Fiona Cooke, MA, PhD, MSc, FRCPath, MRCP, DTM&H

Research Fellow and Medical Microbiologist

Wellcome Trust Sanger Institute

Department of Microbiology

Addenbrooke's Hospital




FC declares that she has no competing interests.

Christopher D. Huston, MD

Assistant Professor of Medicine

Division of Infectious Diseases

University of Vermont College of Medicine




CDH declares that he has no competing interests.

William A. Petri, Jr, MD, PhD, FACP

Chief and Professor of Medicine

Division of Infectious Diseases and International Health

University of Virginia Health System




WAP declares that he has no competing interests.

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