Massive azoturia and failure to achieve positive nitrogen balance in a botulism patient

Observations of a patient with botulism requiring mechanical ventilatory support for 59 days and hospitalization for approximately 3 months are reported. During the time of greatest muscular paralysis, urinary urea nitrogen excretion exceeded 20 g per day. This degree of azoturia was thought to be due to obligate loss of lean body tissue secondary to paralysis and not to stress or starvation related demands. A contributing factor to the magnitude of azoturia was the presence of a large premorbid body frame and muscle mass. The nutritional goal was not to achieve nitrogen balance but to maintain visceral protein stores. As the patient improved neurologically, the azoturia decreased allowing a positive nitrogen balance with a rebuilding of skeletal muscle.