The Eyes Have It: A Man with Ophthalmoplegia and Dyspnea

He reported drinking alcohol before presentation and noted a sensation of tongue swelling and difficulty breathing. Treatment for anaphylaxis led to no improvement. Examination showed complete ophthalmoplegia, and vocal cord paresis was seen on laryngoscopy. Over the next 2 days, he developed symmetric descending paralysis with areflexia, culminating in respiratory failure. Cerebrospinal fluid and nerve-conduction studies were both unremarkable. A serum sample was positive for botulinum neurotoxin type A; his mother reported he frequently consumed improperly stored foods.