arsenal in the 1950s and 1960s, and was weaponized by Iraq in the 1980s The Aum Shinrikyo cult in Japan tried unsuccessfully to disseminate botulinum toxin before deciding to release sarin in the Tokyo subway system Pathophysiology Botulinum toxins are produced by certain strains of Clostridium botulinum, a strictly anaerobic spore-forming gram-positive rod commonly found in soil Most cases of naturally occurring botulism result from ingestion of preformed toxin (food poisoning) or intestinal toxin formation (infant form) Infant botulism has additional unique epidemiologic considerations; more extensive discussion of this disease, and of botulism in general, may be found elsewhere in this text (see Chapters 82 Weakness and 97 Neurologic Emergencies ) The botulinum neurotoxins are the most toxic substances known to man These toxins function at the peripheral cholinergic presynaptic nerve terminals, principally the neuromuscular junction, by preventing the release of acetylcholine and thereby leading to a generalized flaccid paralysis and autonomic symptoms In keeping with the fact that toxins are chemical poisons produced by biologic organisms, it is important to keep in mind that cases of botulism arising from a terrorist attack represent intoxication rather than infection caused by replicating C botulinum organisms Clinical Manifestations Following a latent period ranging from 24 hours to several days, victims begin to experience cranial nerve dysfunction, manifesting as bulbar palsy, ptosis, photophobia, and blurred vision owing to difficulty in accommodation Symptoms progress to include dysarthria, dysphonia, and dysphagia Ultimately, a descending, symmetric, flaccid paralysis ensues, although sensorium and sensation are not affected primarily The mucous membranes are dry; this fact, along with mydriasis, the nature of the paralysis (lack of initial fasciculations), and the latent period, all differentiate botulism from nerve-agent intoxication A solitary case of botulism must also be differentiated from myasthenia gravis, Guillain–Barré syndrome, tick paralysis, and a few other uncommon neurologic disorders The presence of multiple casualties with similar symptoms should raise the concern for botulism Management Supportive care, with meticulous attention to ventilatory support, remains the mainstay of botulism management Patients may require such support for several months, making the management of a large-scale botulism outbreak especially problematic in terms of medical resources A heptavalent (types A to G) despeciated (Fab2) equine botulinum antitoxin was licensed in 2013 for the management of noninfant botulism and is available through the CDC Although