The key role of the ophthalmologist in diagnosing botulism: two case reports

Botulinum toxin, the strongest known neurotoxin, is the cause of a rare fatal neuroparalytic disease characterized by the so-called "four Ds": diplopia, dysarthria, dysphagia, dry mouth. If left untreated, botulism may cause paralysis of the respiratory muscles, impairing the respiratory function which can ultimately lead to death.

We describe the cases of two patients who presented, two years apart, with similar ocular symptoms such as blurred vision due to accommodation palsy, diplopia, accompanied by xerostomia and swallowing disorders, which were further confirmed as botulism. Both cases had a similar clinical presentation of the intoxication and a positive response to treatment with botulinum antitoxin, while only the first case had a laboratory confirmation of the disease.

The key to diagnose botulism correctly is based on high clinical suspicion and requires a medical multidisciplinary approach and urgent specific treatment. Ophthalmology specialists must be aware of the disease, especially in cases in which ophthalmic manifestation appear at the onset.