779 - Botulism in a Simultaneous Pancreas Kidney Transplant Recipient: Rehabilitation Course, Complications, and Prognosis

Case Diagnosis: Botulism

Case Description: 36-year-old female with type 1 diabetes, end-stage renal disease, and simultaneous pancreas kidney transplant presented two months post-transplant with positional dizziness and diffuse weakness. Symptoms progressed to difficulty keeping her eyes open and swallowing. Workup included inconclusive EMG, imaging, and bloodwork. However, Department of Health testing confirmed botulism from unpasteurized honey brought in by her husband.

Prior to presentation patient was independent for all ADLs. She was admitted to the acute rehabilitation unit two weeks after symptom onset with proximal greater than distal muscle weakness (mostly 2/5 and 3/5), worsening neck flexor weakness, bilateral ptosis, dysarthria, and dysphagia. Sensation, reflexes, bowel and bladder function were preserved. Rehabilitation course was complicated by immunosuppression, orthostatic hypotension requiring midodrine, swallowing impaired by esophageal retention, and profound weakness limiting function.

Discussions: With one month of speech, physical, and occupational therapy the patient improved from min- and mod-assist for all ADLs to contact-guard or modified-independent. Improvement in swallowing allowed for advancement of easy-to-chew diet to regular diet with thin liquids. Four months later with outpatient therapy strength improved to 4/5 or 5/5 throughout. She reported no limitations with ambulating, no assistive device, and independence for all ADLs.

This case report highlights the unique presentation, complications, rehabilitation course, and functional prognosis of a pancreas kidney transplant recipient infected with botulism. The comprehensive therapy program initiated within two weeks of symptom onset targeted this patient’s declining functional status, ultimately recovering her strength, swallowing, and independence.

Conclusions: Inpatient rehabilitation with targeted therapy regimens in the immediate aftermath of botulism infection can be essential for patients to increase strength, improve swallowing, and regain independence at home and in the community.