Differential Diagnosis

• Single most likely diagnosis
  • Clostridium botulinum: The patient's symptoms, including diplopia, difficulty speaking, drooling, nausea, vomiting, ptosis, and inability to adduct the eyes or look down toward the nose, are consistent with botulism. The fact that many other people who attended the game have developed similar symptoms and two people died suggests a foodborne or waterborne outbreak, which is consistent with botulism caused by contaminated food or drink.
• Other Likely diagnoses
  • Bacillus anthracis: Although less likely, anthrax infection could potentially cause a range of symptoms, including respiratory distress, which is reported in other people who attended the game. However, the specific symptoms of diplopia, ptosis, and difficulty speaking are more characteristic of botulism.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • Yersinia pestis: Plague is a highly infectious and deadly disease that can cause a range of symptoms, including respiratory distress. Although the symptoms do not perfectly match those of plague, the potential for high mortality makes it a "do not miss" diagnosis.
  • Francisella tularensis: Tularemia can cause a range of symptoms, including respiratory distress, and can be highly infectious. Like plague, the potential for high mortality makes it a "do not miss" diagnosis.
• Rare diagnoses
  • Coxiella burnetii: Q fever is a rare disease that can cause a range of symptoms, including respiratory distress. However, the specific symptoms of diplopia, ptosis, and difficulty speaking are not characteristic of Q fever, making it a less likely diagnosis.