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The incubation period is longer in wound botulism, typically 4 14 days in comparison to hours for toxin or spore ingestion In cases of suspected wound botulism, the integument should be carefully searched, not only for gross disruption and wound contamination, but also for minor bruising with or without signs of infection Culture of these areas should be performed for anaerobic organisms The nasal mucosa should also be carefully evaluated The phenotype of infantile botulism can range from mild symptoms to sudden death Constipation is a relatively constant and sometimes the sole symptom in mild cases Affected children may appear listless with diminished spontaneous movements Parents may note that the child has a diminished suck In more severe forms of the disease, the child is hypotonic and oppy Excessive drooling accompanied by a weak cry is particularly worrisome Ptosis and smoothing of facial expression may be noted Repeatedly testing pupillary constriction may reveal fatigue of this response Reduced head control and gag re ex may also be noted Inserting one s nger into the infant s mouth reveals a weak sucking action compared to healthy infants Deep tendon re exes may be present or diminished With disease progression, infants become are exic Ventilatory function should be closely monitored, as approximately 50% of infants require assisted mechanical ventilation Both ventilatory muscle weakness and airway obstruction from pharyngeal muscle weakness may be contributory Several weeks may be required prior to patient recovery Similar to adults, infants infected with botulinum toxin (BTX) A tend to have a more severe disease course than those infected with BTX B During the recovery phase, the infants may continue to shed toxin and organisms from the stool This does not implicate that the disease is refractory to treatment Eventually, bowel ora returns to normal

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other hand, adult men are more likely to be affected than women presumptively because of increased exposure to wooded areas Patients typically present with ascending weakness evolving over the course of a few hours or days to accid paralysis239 242,245 254 Children are often quite irritable Cranial nerve involvement including internal and external ophthalmoplegia, facial weakness, dysarthria, and dysphagia occur commonly Ventilatory muscle weakness is a common feature as well Patients may complain of pain, numbness, and uncomfortable paresthesias, such as itching or burning in the extremities Despite these complaints, objective sensory loss is mild and typically restricted to initial stages of the disease Occasional patients may develop sensory ataxia, past-pointing, and decreased heel-to-shin and nger-tonose ability Deep tendon re exes are diminished or absent The onset and course are usually more abrupt on average than seen in most cases of Guillain Barr syne drome, but this is of little value as a discriminator in individual cases255

A detailed description of the electrodiagnostic EDX features of MG and other DNMT is provided in 2256 In summary, routine motor and sensory conduction studies are typically normal Fibrillation potentials and positive waves are uncommon but may occur, particularly in paraspinal, bulbar, and proximal muscles257 Their prevalence increases in patients who are signi cantly affected by generalized disease258 260 Their presence may lead the electrodiagnostician away from a diagnosis of MG if unaware of this unusual nding Short-duration, low-amplitude motor unit action potentials (MUAPs) associated with early recruitment may occur This pattern results from neuromuscular blockade and an effective reduction in the number of functional myo bers within a given motor unit258 273 This pattern, ie, brillation potentials and small MUAPs, is similar to the needle electromyography (EMG) ndings in in ammatory myopathies As a result, the possibility of a coexisting in ammatory myopathy may be overlooked Serum CK values may aid in resolving this potential problem Demonstration of unstable MUAP variability (instability) is a very helpful EDX tool in MG (Fig 23 2) MUAP variability can be easily demonstrated if sought for To do so, a single MUAP is isolated and viewed repetitively using a delayed trigger line coupled with an increased lowfrequency lter setting (500 Hz) and fast sweep speed (1 2 m/s) This MUAP variability is analogous to the decremental response to slow repetitive stimulation,

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Tick paralysis is a rare but fascinating cause of acute generalized weakness caused by a salivary toxin from selected species of ticks Its classi cation is a matter of some controversy It is discussed here in DNMT, as the pathophysiology of at least one species appears to involve neuromuscular blockade and as abnormal responses to repetitive stimulation have been suggested (see below) In all probability, it should be more accurately considered as a toxic neuropathy, as the majority of known varieties of this disorder appear to represent nerve channel poisons Children are three times as likely to be af icted with tick paralysis as adults239 244 One hypothesis for this discrepancy is the added opportunities for attachment on the long hair of short-statured young girls On the

Polyphasic:

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2 Place the oppy with your text le in the machine that needs restoration Launch the Recovery Console, locate the text le, and execute the following batch command to restore the Registry to a working state:

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