Differential Diagnosis for 67 year old with Peripheral Neuropathy, Ophthalmoplegia, Quadriparesis, Dysphagia, and Worsening Delirium

• Single Most Likely Diagnosis
  • Botulism: This condition is characterized by the symptoms described, including peripheral neuropathy, ophthalmoplegia (weakness or paralysis of the eye muscles), quadriparesis (weakness of all four limbs), dysphagia (difficulty swallowing), and delirium. Botulism is caused by the toxin produced by Clostridium botulinum and can be foodborne, infant, or wound botulism. The combination of these specific neurological symptoms makes botulism a strong candidate for the single most likely diagnosis.
• Other Likely Diagnoses
  • Guillain-Barré Syndrome: An autoimmune disorder that can cause rapid-onset muscle weakness, often triggered by an infection. It can lead to quadriparesis, dysphagia, and respiratory failure but typically does not cause ophthalmoplegia as an initial symptom. However, it's a consideration due to the overlap in neurological deficits.
  • Myasthenia Gravis: An autoimmune disease that leads to muscle weakness and fatigue. While it can cause ophthalmoplegia, dysphagia, and muscle weakness, the pattern of weakness and the presence of peripheral neuropathy might not fully align with myasthenia gravis.
  • Miller Fisher Syndrome: A rare variant of Guillain-Barré Syndrome characterized by ophthalmoplegia, ataxia, and areflexia. It could be considered given the ophthalmoplegia but typically lacks the severe quadriparesis and peripheral neuropathy described.
• Do Not Miss Diagnoses
  • Stroke (especially brainstem stroke): Although less likely given the combination of symptoms, a stroke in the brainstem could potentially cause some of these symptoms, including ophthalmoplegia, dysphagia, and quadriparesis. Missing a stroke could be catastrophic.
  • Wernicke's Encephalopathy: Caused by thiamine deficiency, it can lead to ophthalmoplegia, ataxia, and confusion. Given the delirium and potential for ophthalmoplegia, this diagnosis is critical not to miss, as it is treatable with thiamine supplementation.
• Rare Diagnoses
  • Mitochondrial Myopathies: A group of disorders caused by mitochondrial dysfunction, which can lead to a variety of neurological and muscular symptoms, including ophthalmoplegia and muscle weakness. However, the acute onset of severe symptoms like quadriparesis and delirium would be unusual.
  • Tick Paralysis: A rare condition caused by the neurotoxin in the saliva of certain ticks, leading to ascending paralysis that can mimic Guillain-Barré Syndrome. It's rare and typically associated with the presence of an attached tick or recent tick exposure.