{"version":"1.0.0","segments":[{"startTime":0.218,"endTime":3.3,"body":"[upbeat intro music]"},{"startTime":3.3,"endTime":5.71,"body":"[Dr. Handy] Hi, welcome"},{"startTime":3.3,"endTime":5.71,"body":"to Harrison's PodClass,"},{"startTime":5.71,"endTime":8.83,"body":"where we discuss important"},{"startTime":5.71,"endTime":8.83,"body":"concepts in internal medicine."},{"startTime":8.83,"endTime":9.96,"body":"I'm Cathy Handy."},{"startTime":9.96,"endTime":11.726,"body":"[Dr. Wiener] And I'm Charlie"},{"startTime":9.96,"endTime":11.726,"body":"Wiener, and we're coming to you"},{"startTime":11.726,"endTime":13.84,"body":"from the Johns Hopkins School of Medicine."},{"startTime":15.9,"endTime":17.68,"body":"[Dr. Handy] Welcome to episode 92,"},{"startTime":17.68,"endTime":19.9,"body":"a 24-year-old with weakness."},{"startTime":19.9,"endTime":22.733,"body":"[Dr. Wiener] Hey, Cathy."},{"startTime":19.9,"endTime":22.733,"body":"So, today's patient is"},{"startTime":22.733,"endTime":26.27,"body":"a 24-year-old woman with a"},{"startTime":22.733,"endTime":26.27,"body":"history of developmental delay,"},{"startTime":26.27,"endTime":27.77,"body":"who lives in a group home"},{"startTime":27.77,"endTime":29.48,"body":"and is brought to the"},{"startTime":27.77,"endTime":29.48,"body":"hospital for weakness"},{"startTime":29.48,"endTime":32.64,"body":"starting in her head and"},{"startTime":29.48,"endTime":32.64,"body":"descending to her legs."},{"startTime":32.64,"endTime":34.45,"body":"Obtaining a more complete history,"},{"startTime":34.45,"endTime":37.94,"body":"you find out that the first"},{"startTime":34.45,"endTime":37.94,"body":"symptoms that the staff noticed"},{"startTime":37.94,"endTime":41.22,"body":"were lethargy and what"},{"startTime":37.94,"endTime":41.22,"body":"the people there thought"},{"startTime":41.22,"endTime":43.61,"body":"were an expressionless face."},{"startTime":43.61,"endTime":45.23,"body":"On physical examination,"},{"startTime":45.23,"endTime":48.43,"body":"you find that she has symmetric"},{"startTime":45.23,"endTime":48.43,"body":"cranial nerve palsies,"},{"startTime":48.43,"endTime":51.582,"body":"inability to move, and"},{"startTime":48.43,"endTime":51.582,"body":"decreased breathing."},{"startTime":51.582,"endTime":53.97,"body":"Her deep tendon reflexes are normal."},{"startTime":53.97,"endTime":55.53,"body":"Further examination reveals"},{"startTime":55.53,"endTime":58.29,"body":"that she's taking only"},{"startTime":55.53,"endTime":58.29,"body":"shallow respirations"},{"startTime":58.29,"endTime":61.52,"body":"and you note flaccid muscle"},{"startTime":58.29,"endTime":61.52,"body":"tone throughout her body."},{"startTime":61.52,"endTime":62.9,"body":"According to her caretaker,"},{"startTime":62.9,"endTime":66.46,"body":"there was no preceding"},{"startTime":62.9,"endTime":66.46,"body":"fever, diarrhea, cough,"},{"startTime":66.46,"endTime":69.57,"body":"coryza, rash, or new medications."},{"startTime":69.57,"endTime":72.72,"body":"She was recently given"},{"startTime":69.57,"endTime":72.72,"body":"amoxicillin / clavulanate"},{"startTime":72.72,"endTime":75.613,"body":"for sinusitis. The group home has a diet"},{"startTime":75.613,"endTime":79.73,"body":"consisting mostly of foods"},{"startTime":75.613,"endTime":79.73,"body":"created with prepared meats."},{"startTime":79.73,"endTime":81.38,"body":"The question's going to ask,"},{"startTime":81.38,"endTime":82.42,"body":"which of the following"},{"startTime":82.42,"endTime":85.31,"body":"is the most likely cause"},{"startTime":82.42,"endTime":85.31,"body":"of her presentation?"},{"startTime":85.31,"endTime":88.97,"body":"And the options are,"},{"startTime":85.31,"endTime":88.97,"body":"A. botulinum toxicity;"},{"startTime":88.97,"endTime":91.59,"body":"B. Guillain-Barre syndrome;"},{"startTime":91.59,"endTime":95.35,"body":"C. hypokalemic periodic paralysis;"},{"startTime":95.35,"endTime":97.78,"body":"D. tetanus toxicity;"},{"startTime":97.78,"endTime":100.61,"body":"or E. tick paralysis."},{"startTime":100.61,"endTime":103.35,"body":"[Dr. Handy] Okay, this is a"},{"startTime":100.61,"endTime":103.35,"body":"bit of a strange presentation,"},{"startTime":103.35,"endTime":105.97,"body":"but there're some key findings"},{"startTime":103.35,"endTime":105.97,"body":"here that I'll point out."},{"startTime":105.97,"endTime":109.21,"body":"So one is that she had what's"},{"startTime":105.97,"endTime":109.21,"body":"described as descending"},{"startTime":109.21,"endTime":111.18,"body":"rather than ascending weakness,"},{"startTime":111.18,"endTime":114.55,"body":"and a syndrome characterized"},{"startTime":111.18,"endTime":114.55,"body":"by flaccid weakness,"},{"startTime":114.55,"endTime":117.11,"body":"the symmetric cranial nerve palsies,"},{"startTime":117.11,"endTime":119.55,"body":"clearly, she has respiratory"},{"startTime":117.11,"endTime":119.55,"body":"muscle involvement,"},{"startTime":119.55,"endTime":123.26,"body":"and notably has normal"},{"startTime":119.55,"endTime":123.26,"body":"deep tendon reflexes."},{"startTime":123.26,"endTime":125.92,"body":"[Dr. Wiener] Okay. So what do"},{"startTime":123.26,"endTime":125.92,"body":"those findings make you think?"},{"startTime":125.92,"endTime":127.23,"body":"[Dr. Handy] So, putting that together,"},{"startTime":127.23,"endTime":130.02,"body":"I would say that she has A. botulism."},{"startTime":130.02,"endTime":132.49,"body":"So, botulism is still a real thing."},{"startTime":132.49,"endTime":136.39,"body":"It probably comes up more in"},{"startTime":132.49,"endTime":136.39,"body":"Board exams than in real life,"},{"startTime":136.39,"endTime":140.27,"body":"but it's a neuroparalytic disease"},{"startTime":136.39,"endTime":140.27,"body":"caused by botulinum toxin,"},{"startTime":140.27,"endTime":142.87,"body":"one of the most toxic substances known."},{"startTime":142.87,"endTime":145.78,"body":"Her syndrome with bilateral"},{"startTime":142.87,"endTime":145.78,"body":"cranial nerve palsies"},{"startTime":145.78,"endTime":149.38,"body":"with descending voluntary"},{"startTime":145.78,"endTime":149.38,"body":"muscle paralysis is typical."},{"startTime":149.38,"endTime":150.34,"body":"And it's important to know"},{"startTime":150.34,"endTime":152.38,"body":"this constellation of symptoms and signs"},{"startTime":152.38,"endTime":154.81,"body":"because it's often not suspected."},{"startTime":154.81,"endTime":158.56,"body":"The ptosis and facial paralysis"},{"startTime":154.81,"endTime":158.56,"body":"too does initially manifest"},{"startTime":158.56,"endTime":161.51,"body":"as lethargy and expressionless faces."},{"startTime":161.51,"endTime":163.451,"body":"[Dr. Wiener] Okay, well,"},{"startTime":161.51,"endTime":163.451,"body":"let's talk about how would one"},{"startTime":163.451,"endTime":165.34,"body":"get it and how do you think she got it?"},{"startTime":165.34,"endTime":167.318,"body":"[Dr. Handy] While initially"},{"startTime":165.34,"endTime":167.318,"body":"thought to be caused only by"},{"startTime":167.318,"endTime":170.64,"body":"the ingestion of botulinum"},{"startTime":167.318,"endTime":170.64,"body":"toxin in contaminated food"},{"startTime":170.64,"endTime":172.99,"body":"or so-called foodborne botulism,"},{"startTime":172.99,"endTime":176.38,"body":"three additional forms caused"},{"startTime":172.99,"endTime":176.38,"body":"by in-situ toxin production"},{"startTime":176.38,"endTime":179.33,"body":"after germination of"},{"startTime":176.38,"endTime":179.33,"body":"spores in either a wound"},{"startTime":179.33,"endTime":181.89,"body":"or the intestine are now"},{"startTime":179.33,"endTime":181.89,"body":"recognized worldwide."},{"startTime":181.89,"endTime":185.05,"body":"So, that would be wound"},{"startTime":181.89,"endTime":185.05,"body":"botulism, infant botulism,"},{"startTime":185.05,"endTime":188.31,"body":"and adult intestinal"},{"startTime":185.05,"endTime":188.31,"body":"colonization botulism."},{"startTime":188.31,"endTime":189.87,"body":"So in addition to occurring"},{"startTime":189.87,"endTime":192.34,"body":"in these recognized natural"},{"startTime":189.87,"endTime":192.34,"body":"forms of the disease,"},{"startTime":192.34,"endTime":195.72,"body":"botulism symptoms have been"},{"startTime":192.34,"endTime":195.72,"body":"reported in patients receiving"},{"startTime":195.72,"endTime":198.16,"body":"higher than recommended doses of Botox,"},{"startTime":198.16,"endTime":200.54,"body":"which would be considered"},{"startTime":198.16,"endTime":200.54,"body":"iatrogenic botulism"},{"startTime":200.54,"endTime":203.05,"body":"for therapeutic or cosmetic purposes."},{"startTime":203.05,"endTime":205.613,"body":"[Dr. Wiener] Okay. So now"},{"startTime":203.05,"endTime":205.613,"body":"you have my attention about"},{"startTime":205.613,"endTime":207.888,"body":"botulism, let's talk a"},{"startTime":205.613,"endTime":207.888,"body":"little bit more about it"},{"startTime":207.888,"endTime":209.05,"body":"and how common is it?"},{"startTime":209.05,"endTime":212.26,"body":"You mentioned that it's more"},{"startTime":209.05,"endTime":212.26,"body":"on Board exams than real life."},{"startTime":212.26,"endTime":214.56,"body":"[Dr. Handy] So it's hard to"},{"startTime":212.26,"endTime":214.56,"body":"know the epidemiology exactly"},{"startTime":214.56,"endTime":215.99,"body":"because of variable reporting,"},{"startTime":215.99,"endTime":219.63,"body":"but in the U. S. there are about"},{"startTime":215.99,"endTime":219.63,"body":"20 sporadic cases per year."},{"startTime":219.63,"endTime":221.67,"body":"There have been a few"},{"startTime":219.63,"endTime":221.67,"body":"outbreaks in this country."},{"startTime":221.67,"endTime":224.15,"body":"In 2006, commercially produced"},{"startTime":224.15,"endTime":227.23,"body":"and internationally distributed"},{"startTime":224.15,"endTime":227.23,"body":"carrot juice was implicated."},{"startTime":227.23,"endTime":228.59,"body":"Inappropriate refrigeration"},{"startTime":228.59,"endTime":230.25,"body":"in the setting of a lack of barriers"},{"startTime":230.25,"endTime":233.8,"body":"to botulinum toxin production"},{"startTime":230.25,"endTime":233.8,"body":"was believed to be the cause."},{"startTime":233.8,"endTime":236.43,"body":"Then in 2007, botulism developed"},{"startTime":236.43,"endTime":238.67,"body":"in about eight people in the United States"},{"startTime":238.67,"endTime":242.52,"body":"who had consumed a canned"},{"startTime":238.67,"endTime":242.52,"body":"hot dog chili sauce."},{"startTime":242.52,"endTime":245.08,"body":"Significant deficiencies were"},{"startTime":242.52,"endTime":245.08,"body":"discovered in that setting."},{"startTime":245.08,"endTime":246.73,"body":"That involved 91 different products"},{"startTime":246.73,"endTime":250.44,"body":"and resulted in the recall"},{"startTime":246.73,"endTime":250.44,"body":"of 111 million cans of food."},{"startTime":250.44,"endTime":251.849,"body":"[Dr. Wiener] So back to our patient,"},{"startTime":251.849,"endTime":253.249,"body":"do you think she has foodborne"},{"startTime":253.249,"endTime":255.8,"body":"or do you think she has"},{"startTime":253.249,"endTime":255.8,"body":"intestinal colonization botulism?"},{"startTime":255.8,"endTime":258.46,"body":"Because those seem like"},{"startTime":255.8,"endTime":258.46,"body":"the likely choices for her."},{"startTime":258.46,"endTime":260.325,"body":"[Dr. Handy] Yeah, I suspect"},{"startTime":258.46,"endTime":260.325,"body":"since she seems to be"},{"startTime":260.325,"endTime":262.33,"body":"the only person at the"},{"startTime":260.325,"endTime":262.33,"body":"group home that's ill"},{"startTime":262.33,"endTime":265.27,"body":"that she has intestinal"},{"startTime":262.33,"endTime":265.27,"body":"colonization botulism"},{"startTime":265.27,"endTime":267.26,"body":"because nobody else was affected,"},{"startTime":267.26,"endTime":269.53,"body":"but this form is difficult to confirm"},{"startTime":269.53,"endTime":270.78,"body":"because it's poorly understood."},{"startTime":270.78,"endTime":272.78,"body":"So there are no clear criteria available"},{"startTime":272.78,"endTime":274.16,"body":"to differentiate cases"},{"startTime":274.16,"endTime":276.74,"body":"of adult intestinal colonization botulism"},{"startTime":276.74,"endTime":278.8,"body":"from other adult botulism cases."},{"startTime":278.8,"endTime":282.35,"body":"Often these cases are caused"},{"startTime":278.8,"endTime":282.35,"body":"by Clostridium baratii type F,"},{"startTime":282.35,"endTime":285.59,"body":"but the involvement of"},{"startTime":282.35,"endTime":285.59,"body":"both C. botulinum type A"},{"startTime":285.59,"endTime":289.4,"body":"and C. butyricum type"},{"startTime":285.59,"endTime":289.4,"body":"E have been reported."},{"startTime":289.4,"endTime":292.48,"body":"Botulism following abdominal"},{"startTime":289.4,"endTime":292.48,"body":"surgery or antibiotic use"},{"startTime":292.48,"endTime":293.72,"body":"has sometimes been considered"},{"startTime":293.72,"endTime":296.84,"body":"likely adult intestinal"},{"startTime":293.72,"endTime":296.84,"body":"colonization botulism."},{"startTime":296.84,"endTime":298.65,"body":"[Dr. Wiener] I can understand"},{"startTime":296.84,"endTime":298.65,"body":"the pathophysiology"},{"startTime":298.65,"endTime":300.33,"body":"if someone ingests the toxin,"},{"startTime":300.33,"endTime":303.67,"body":"but what about these cases"},{"startTime":300.33,"endTime":303.67,"body":"of intestinal colonization?"},{"startTime":303.67,"endTime":305.449,"body":"What's the pathophysiology there?"},{"startTime":305.449,"endTime":306.705,"body":"[Dr. Handy] So, like I"},{"startTime":305.449,"endTime":306.705,"body":"mentioned before, it's poorly"},{"startTime":306.705,"endTime":309.21,"body":"understood, it's believed"},{"startTime":306.705,"endTime":309.21,"body":"to have a pathology"},{"startTime":309.21,"endTime":312.77,"body":"similar to that of infant"},{"startTime":309.21,"endTime":312.77,"body":"botulism but it occurs in adults."},{"startTime":312.77,"endTime":314.76,"body":"Typically, patients have some anatomic"},{"startTime":314.76,"endTime":316.61,"body":"or functional bowel abnormality,"},{"startTime":316.61,"endTime":319.13,"body":"or have recently used"},{"startTime":316.61,"endTime":319.13,"body":"antibiotics that may help"},{"startTime":319.13,"endTime":321.77,"body":"toxigenic Clostridium"},{"startTime":319.13,"endTime":321.77,"body":"compete more successfully"},{"startTime":321.77,"endTime":323.94,"body":"against the normal bowel microbiota."},{"startTime":323.94,"endTime":325.65,"body":"Despite antitoxin treatment,"},{"startTime":325.65,"endTime":328.58,"body":"relapse due to intermittent"},{"startTime":325.65,"endTime":328.58,"body":"intraluminal production of toxin"},{"startTime":328.58,"endTime":329.94,"body":"may be observed in patients"},{"startTime":329.94,"endTime":332.88,"body":"with adult intestinal"},{"startTime":329.94,"endTime":332.88,"body":"colonization botulism."},{"startTime":332.88,"endTime":334.13,"body":"[Dr. Wiener] And we"},{"startTime":332.88,"endTime":334.13,"body":"noted that this patient"},{"startTime":334.13,"endTime":335.8,"body":"had received antibiotics recently,"},{"startTime":335.8,"endTime":338.24,"body":"so maybe that was the precipitating cause."},{"startTime":338.24,"endTime":340.8,"body":"You mentioned antitoxin,"},{"startTime":338.24,"endTime":340.8,"body":"is that how you treat this?"},{"startTime":340.8,"endTime":342.64,"body":"[Dr. Handy] The cornerstones"},{"startTime":340.8,"endTime":342.64,"body":"of treatment for botulism"},{"startTime":342.64,"endTime":344.25,"body":"are meticulous intensive care"},{"startTime":344.25,"endTime":347.24,"body":"and administration of botulinum antitoxin."},{"startTime":347.24,"endTime":349.33,"body":"Because antitoxin is most beneficial"},{"startTime":349.33,"endTime":351.07,"body":"early in the course of clinical illness,"},{"startTime":351.07,"endTime":352.89,"body":"it should be administered empirically"},{"startTime":352.89,"endTime":355.81,"body":"and before the time consuming"},{"startTime":352.89,"endTime":355.81,"body":"workup for other illnesses"},{"startTime":355.81,"endTime":358.17,"body":"or laboratory confirmation is complete."},{"startTime":358.17,"endTime":361.21,"body":"Now, persons of all ages in"},{"startTime":358.17,"endTime":361.21,"body":"whom botulism is suspected"},{"startTime":361.21,"endTime":362.84,"body":"should be hospitalized immediately"},{"startTime":362.84,"endTime":364.59,"body":"so that signs of respiratory failure"},{"startTime":364.59,"endTime":366.67,"body":"can be detected and managed."},{"startTime":366.67,"endTime":369.11,"body":"Vital capacity should"},{"startTime":366.67,"endTime":369.11,"body":"be monitored frequently,"},{"startTime":369.11,"endTime":372.47,"body":"and mechanical ventilation"},{"startTime":369.11,"endTime":372.47,"body":"can be provided as needed."},{"startTime":372.47,"endTime":375.52,"body":"The botulinum antitoxin can"},{"startTime":372.47,"endTime":375.52,"body":"limit the progression of illness"},{"startTime":375.52,"endTime":378.6,"body":"because it neutralizes toxin"},{"startTime":375.52,"endTime":378.6,"body":"molecules in the circulation"},{"startTime":378.6,"endTime":380.56,"body":"that have not yet bound to nerve endings,"},{"startTime":380.56,"endTime":383.36,"body":"but it really doesn't"},{"startTime":380.56,"endTime":383.36,"body":"reverse existing paralysis,"},{"startTime":383.36,"endTime":385.82,"body":"which can take weeks to improve."},{"startTime":385.82,"endTime":386.69,"body":"Clinical improvement"},{"startTime":386.69,"endTime":388.56,"body":"follows sprouting of new nerve terminals,"},{"startTime":388.56,"endTime":390.949,"body":"so it can take weeks to months."},{"startTime":390.949,"endTime":393.42,"body":"[Dr. Wiener] So, yeah, so I"},{"startTime":390.949,"endTime":393.42,"body":"assume that the overall recovery"},{"startTime":393.42,"endTime":395.51,"body":"for a patient such as"},{"startTime":393.42,"endTime":395.51,"body":"this is pretty slow then?"},{"startTime":395.51,"endTime":396.7,"body":"[Dr. Handy] Yeah, patients often require"},{"startTime":396.7,"endTime":398.397,"body":"outpatient rehabilitation therapy"},{"startTime":398.397,"endTime":400.81,"body":"and may experience residual deficits."},{"startTime":400.81,"endTime":402.33,"body":"Death in untreated botulism"},{"startTime":402.33,"endTime":403.97,"body":"is usually due to respiratory failure"},{"startTime":403.97,"endTime":405.38,"body":"related to airway obstruction,"},{"startTime":405.38,"endTime":407.42,"body":"that's from pharyngeal muscle paralysis"},{"startTime":407.42,"endTime":408.98,"body":"and inadequate tidal volume,"},{"startTime":408.98,"endTime":411.11,"body":"resulting from paralysis of diaphragmatic"},{"startTime":411.11,"endTime":413.37,"body":"and accessory respiratory muscles."},{"startTime":413.37,"endTime":416.26,"body":"Death can also result from"},{"startTime":413.37,"endTime":416.26,"body":"hospital-associated infections"},{"startTime":416.26,"endTime":418.58,"body":"and other sequela of long-term paralysis,"},{"startTime":418.58,"endTime":421.75,"body":"hospitalizations, and"},{"startTime":418.58,"endTime":421.75,"body":"mechanical ventilation."},{"startTime":421.75,"endTime":423.696,"body":"[Dr. Wiener] Okay, let's run"},{"startTime":421.75,"endTime":423.696,"body":"through the other options"},{"startTime":423.696,"endTime":425.855,"body":"in this question. Why was her presentation"},{"startTime":425.855,"endTime":427.638,"body":"not likely due to them?"},{"startTime":427.638,"endTime":429.085,"body":"[Dr. Handy] All right,"},{"startTime":427.638,"endTime":429.085,"body":"so going down the list,"},{"startTime":429.085,"endTime":431.72,"body":"Guillain-Barre syndrome is"},{"startTime":429.085,"endTime":431.72,"body":"an acute, frequently severe"},{"startTime":431.72,"endTime":434.32,"body":"and fulminant polyradiculoneuropathy"},{"startTime":434.32,"endTime":437.361,"body":"that's autoimmune in nature,"},{"startTime":434.32,"endTime":437.361,"body":"it typically manifests"},{"startTime":437.361,"endTime":440.22,"body":"as a rapidly progressive"},{"startTime":437.361,"endTime":440.22,"body":"ascending paralysis,"},{"startTime":440.22,"endTime":444.35,"body":"often with sensory deficits and"},{"startTime":440.22,"endTime":444.35,"body":"absent deep tendon reflexes,"},{"startTime":444.35,"endTime":447.91,"body":"and remember, in our case,"},{"startTime":444.35,"endTime":447.91,"body":"the reflexes were normal."},{"startTime":447.91,"endTime":450.83,"body":"It is often, about 70%"},{"startTime":447.91,"endTime":450.83,"body":"of the time, associated"},{"startTime":450.83,"endTime":454.624,"body":"with an acute respiratory or"},{"startTime":450.83,"endTime":454.624,"body":"gastrointestinal infection."},{"startTime":454.624,"endTime":455.88,"body":"[Dr. Wiener] How about the others?"},{"startTime":455.88,"endTime":457.81,"body":"[Dr. Handy] Hypokalemic periodic paralysis"},{"startTime":457.81,"endTime":460.45,"body":"is a very rare autosomal dominant disease"},{"startTime":460.45,"endTime":463.59,"body":"and is characterized by sporadic"},{"startTime":460.45,"endTime":463.59,"body":"or episodic acute weakness"},{"startTime":463.59,"endTime":465.65,"body":"that's associated with hypokalemia."},{"startTime":465.65,"endTime":467.92,"body":"The history here didn't sound compatible."},{"startTime":467.92,"endTime":470.01,"body":"Tetanus toxicity causes muscle spasms,"},{"startTime":470.01,"endTime":472.61,"body":"not paralysis and cranial nerve defects."},{"startTime":472.61,"endTime":475.44,"body":"And tick paralysis is"},{"startTime":472.61,"endTime":475.44,"body":"caused by a tick neurotoxin"},{"startTime":475.44,"endTime":477.66,"body":"and may also cause an ascending paralysis"},{"startTime":477.66,"endTime":479.66,"body":"that's more similar to Guillain-Barre."},{"startTime":479.66,"endTime":482.213,"body":"In this case, we also don't"},{"startTime":479.66,"endTime":482.213,"body":"have any history of a tick bite."},{"startTime":482.213,"endTime":483.253,"body":"[Dr. Wiener] Okay, great."},{"startTime":483.253,"endTime":484.88,"body":"So the teaching points in this case"},{"startTime":484.88,"endTime":488.03,"body":"are that botulism presents"},{"startTime":484.88,"endTime":488.03,"body":"with a descending paralysis"},{"startTime":488.03,"endTime":490.21,"body":"with prominent cranial nerve involvement."},{"startTime":490.21,"endTime":491.99,"body":"While most cases are foodborne,"},{"startTime":491.99,"endTime":493.5,"body":"there may be isolated cases"},{"startTime":493.5,"endTime":496.12,"body":"of adult intestinal colonization botulism"},{"startTime":496.12,"endTime":497.37,"body":"that require awareness,"},{"startTime":497.37,"endTime":501.05,"body":"since prompt administration of"},{"startTime":497.37,"endTime":501.05,"body":"the antitoxin is imperative."},{"startTime":501.05,"endTime":502.83,"body":"[Dr. Handy] And you can read"},{"startTime":501.05,"endTime":502.83,"body":"more about it, believe it"},{"startTime":502.83,"endTime":505.685,"body":"or not, Harrison's has a"},{"startTime":502.83,"endTime":505.685,"body":"whole chapter on botulism."},{"startTime":505.685,"endTime":510.107,"body":"[upbeat outro music]"},{"startTime":510.107,"endTime":512.96,"body":"[Mr. Shanahan] This is Jim"},{"startTime":510.107,"endTime":512.96,"body":"Shanahan, publisher at McGraw Hill."},{"startTime":512.96,"endTime":514.59,"body":"Harrison's PodClass is brought to you"},{"startTime":514.59,"endTime":516.58,"body":"by McGraw Hill's AccessMedicine,"},{"startTime":516.58,"endTime":518.595,"body":"the online medical resource that delivers"},{"startTime":518.595,"endTime":521.904,"body":"the latest trusted content from"},{"startTime":518.595,"endTime":521.904,"body":"the best minds in medicine."},{"startTime":521.904,"endTime":524.453,"body":"Go to accessmedicine.com to learn more."}]}