"Bolthouse Farms, Bakersfield, California, 100% carrot juice" has been confirmed as the cause of a cluster of three botulism cases that were reported on September 8 in Georgia. It is unknown whether the contaminated juice was subjected to time or temperature abuse that might have facilitated the growth of Clostridium botulinum spores, which can survive pasteurization. Clinicians should inquire specifically about consumption of carrot juice in the food history of suspect botulism cases.

Botulism should be suspected in patients with cranial nerve dysfunction manifested as difficulty seeing, speaking and/or swallowing, followed by symmetric descending weakness and paralysis. Clinical hallmarks include ptosis, blurred vision and the "4 Ds': diplopia, dysarthria, dysphonia, and dysphagia. CSF protein is normal in botulism; EMG may help differentiate causes of paralysis.

Initiation of treatment with antitoxin should be based on the clinical diagnosis and should not await laboratory confirmation. Early treatment with botulinum antitoxin is important to prevent progression to respiratory failure, the most frequent cause of death. Wounds suspected of being contaminated with C. botulinum should be widely debrided and irrigated, ideally after the administration of botulinal antitoxin. Anaerobic cultures should be obtained. Mechanical ventilation is the main supportive therapy for severe cases of botulism.

Suspected cases of botulism should be reported to Public Health immediately at 206-296-4774 to facilitate: 1) laboratory confirmation of the diagnosis (submit serum and tissue specimens for suspected wound botulism), 2) assistance in obtaining antitoxin from the Centers for Disease Control and Prevention, and 3) prompt investigation and removal of likely sources of transmission and identification of other persons at risk for illness.

• Patient's address including city; telephone or contact information; names and contact information for of family and/or friends who can be interviewed.
• Name and contact information for other persons with similar symptoms.
• Drugs injection history including drugs injected, preparation (e.g., black tar), dates used in past two weeks; route administered (IV, IM , SC or "skin popping", inhaled); names and contact information for individuals with whom patient shared drugs or works in past 2 weeks.
• Food history for the past 7 days including: group meals or gatherings, home canned foods, other canned foods, vacuum packed foods, seafood, potpies, smoked meats, fish, sausages, honey, and at this time, carrot juice..
• History of gut resection, recent antibiotics, other clinical history to suggest altered gut flora.

More information on botulism by the CDC.