Clinical Practice and Cases in Emergency Medicine

We describe a case of wound botulism initially thought to represent Miller-Fisher variant Guillain-Barré syndrome (MFS). Botulism classically presents with the so-called “four D’s” (diplopia,dysarthria, dysphagia, dry mouth) with symmetric, descending weakness. MFS presents with a triadof limb-ataxia, areflexia, and ophthalmoplegia, with variable cranial nerve and extremity involvement.The distinction can be difficult but is important as early initiation of botulinum antitoxin is associatedwith improved patient outcomes in cases of botulism. Furthermore, it is important to recognizeintravenous drug use as a risk factor in the development of botulism, especially given an increase ininjection drug use.