Hay fever as a Christmas gift.

The authors reply: We appreciate the additional points raised by Rao et al. and would underscore the importance of early initiation of antitoxin treatment in cases of suspected botulism. A retrospective analysis of 132 cases of foodborne botulism reported to the CDC from 1973 through 1980 showed a median hospital stay of 10 days if patients received antitoxin within 24 hours after symptoms began, as compared with 41 days if antitoxin was received after 24 hours of symptoms and 56 days if they did not receive antitoxin.1 Better outcomes were also associated with earlier treatment in a 2006 botulism outbreak involving 209 patients in Thailand who had consumed home-canned bamboo shoots.2-4 We also wish to correct two statements in our article. The statement beginning “Foodborne botulism classically occurs after ingestion of spores” should have read “Foodborne botulism occurs after ingestion of botulinum toxin.” We referred to the availability of “intravenous equine trivalent antitoxin (for types A, B, and E) or bivalent antitoxin (for types A and B)” from state health departments. As pointed out by Rao et al., heptavalent antitoxin is the only antitoxin currently available. Our patient was hospitalized before the availability of this particular antitoxin. The nystagmus was described as rotatory by an observer, but unfortunately, the authors were not present to observe this. We agree with Dr. Pollak that gaze-paretic nystagmus would be more likely. Miten Vasa, M.D.