Situations suggesting release of botulinum toxin as a biological weapon:
(1) Outbreak of acute flaccid paralysis with prominent bulbar palsies (diplopia, dysarthria, dysphonia, dysphagia) in patients who are afebrile and with a clear sensorium.
(2) Outbreak with an unusual botulinum toxin
(2a) type C, D, F, or G
(2b) type E not acquired from an aquatic food
(3) Outbreak with a common geographic factor or activity among cases
(3a) with features favoring an aerosol attack
(3b) common dietary exposure under suspicious circumstances
(4) Multiple simultaneous outbreaks without a common identifiable source.
A patient with symptoms compatible with botulism should have a complete history and physical, with emphasis placed on:
(1) dietary history
(2) travel and activity history
(3) other persons with similar symptoms
