During medical school we are introduced to many diseases, some sparking particular interest because of a personal connection (for example, a past beloved relative afflicted by leukemia) or a discovered thrill over how a certain disease presents. For me, botulism is a disease ripe with dramatic intrigue.1. Vichyssoise.As a child, my first exposure to botulism was at the family dinner table. No, I did not ingest the feared botulinum toxin but I heard about people who did. My father was a storyteller and during our meals he would tell any tale that caught his fancy. One evening at dinner, after my sister complained about having mashed potatoes, my father remarked that we should be glad we were not having potato soup. He proceeded to tell the story of a soup company that declared bankruptcy after several people had died from ingesting a spoonful of vichyssoise soup. Apparently the soup was poorly canned and the affected cans were rife with botulinum toxin, which according to my dad instantly paralyzed the unsuspecting diners, killing them shortly after swallowing that fateful spoon of potato soup. I was captivated.
Dad then explained how a bacterium grew within the can and produced a deadly poison. For me, the vichyssoise story was quite memorable, and I’ve been hooked on the subject of botulism and the science behind that disease ever since.A year or two later, I watched a movie on late-night television entitled, “The Satan Bug,” a political action thriller in which a millionaire activist steals from a top-secret bioweapons laboratory one vial of a deadly virus and several vials of “botulinus” toxin. The protagonist releases the “botulinus” toxin into the air, which aerosolizes and instantly paralyzes nearby members of the investigative crime team. They die within seconds. My fascination with botulism was firmly cemented.
Fast forward to medical school, where I learned that not only did Clostridium botulinum produce a toxin in an anaerobic environment, a toxin that when ingested could rapidly affect nerve synaptic junctions, the organism could also grow in an infant’s gut and slowly produce a toxin that, in turn, could slowly cause infant paralysis. Now I had a disease story with a riveting plot twist, a twist confirmed during residency when I saw several infants with botulism, all with considerable constipation, flaccid paralysis, and the “rag doll” cry.3. The Disappearance of Mr. Davenheim appears in Agatha Christie's Poirot Investigates collection.True clinical reasoning derives from intuitively connecting clues that establish the correct diagnosis. Author Agatha Christie’s character Hercule Poirot demonstrates such exemplary intuitive skill in the short story, “The Disappearance of Mr. Davenheim,” in which Poirot solves a mystery without ever leaving his apartment, never examining the scene of the crime. After reading that story, I always had hoped that someday I would have that experience in real life.
That day came when I was asked to consult on a new admission of an infant with suspected inflicted head trauma who was becoming weaker by the hour. After entering the NICU where the infant and her mother waited for a scheduled head MRI,4 Click here for video demonstrating telltale “rag doll” cry of botulism. I heard the infant weakly cry as I washed my hands. The cry was familiar, yet I asked the charge nurse if the infant had already been sedated for the MRI scan. The nurse said no, which prompted me to ask the mother, “Is your child constipated?” The mother, quite surprised, answered, “Why yes, she hasn’t passed a stool for 3 weeks. How did you know?” My response was that her daughter had a different diagnosis. Yes, the child had infant botulism, I now had a story I could tell my father, and botulism had granted my wish to be Hercule Poirot for at least one day.
This month, Dr. Maria Carrillo-Marquez writes in Pediatrics in Review about the various spellbinding presentations of botulism. As you read about botulism, consider the importance of the gut microbiome, spore contamination of the environment, toxin-tainted food supplies, and biological warfare, all involving a bacterium that can theatrically and lethally paralyze.