attacks causing severe abdominal pain, nausea, vomiting, tachycardia, hypertension, and, in some cases, central and peripheral neuropathies Motor weakness is more common than sensory symptoms, and the proximal muscles are more affected than the distal Autonomic dysfunction and mental status changes also occur Medications (griseofulvin, barbiturates, sulfonamides, and estrogens) as well as stress, infections, and alcohol have been implicated as triggers Diseases of the NMJ can be recognized by their cranial nerve abnormalities and autonomic dysfunction Importantly, sensory function is unaffected In botulism, Clostridium botulinum, a gram-positive anaerobe, produces several potent neurotoxins that prevent presynaptic release of acetylcholine, resulting in descending flaccid paralysis Preformed toxin may be ingested from any incompletely cooked food Botulinum spores are also found in the soils of some areas of the United States, particularly in eastern Pennsylvania and California There are three distinct clinical presentations of natural disease: infant botulism, classic botulism, and wound botulism (see Chapter 97 Neurologic Emergencies ) In addition, the potential use of botulinum toxin as a weapon of bioterrorism has been described (see Chapter 132 Biological and Chemical Terrorism ) TABLE 82.3 CAUSES OF WEAKNESS IN INFANTS Infant botulism Congenital hypothyroidism Inborn errors of metabolism Benign congenital hypotonia Transient/familial myasthenia Congenital muscular dystrophy/myopathies Spinal muscular atrophy Chiari malformation/myelomeningocele Tethered cord Erb palsy Infant botulism is one of the more common causes of generalized weakness seen in young infants ( Table 82.3 ) The bacterial spores are ingested, and then they germinate and colonize in the intestinal tract, leading to in vivo toxin production Infant botulism has been linked to ingestion of honey, which has a high rate of contamination by the spores The spores are also found naturally in soil Areas in which disturbed soil is found, such as construction sites and rural