A 45-year-old woman presented to urgent care suspecting an allergic reaction to foods that were consumed the previous evening. Her condition rapidly deteriorated to include cranial nerve palsies followed by a descending symmetric muscle weakness requiring mechanical ventilation. Botulism was suspected, and after consultation with public health experts at the state health department and Centers for Disease Control and Prevention, treatment with botulism antitoxin was initiated. The patient required prolonged ventilation and rehabilitation but achieved near-complete recovery after several weeks. Botulinum neurotoxin type F was detected in the patient's serum. Serial testing of the patient's clinical specimens was not performed. The patient's rapid progression to severe paralysis with a relatively swift recovery resembles previously described botulism type F cases. Public health investigations were unable to determine whether the patient had foodborne or adult intestinal colonization botulism.

Human ehrlichiosis is a potentially fatal tickborne disease caused by 3 species: Ehrlichia chaffeensis, E. ewingii, and E. muris eauclairensis. In the United States, 234 confirmed cases of E. ewingii ehrlichiosis were reported to the Centers for Disease Control and Prevention through the National Notifiable Diseases Surveillance System during 2013-2021; average annual incidence was 0.08 cases/1 million population. E. ewingii ehrlichiosis was reported more commonly among older, White, non-Hispanic, and male patients. Incidence and case counts generally increased yearly, except for 2020 and 2021. The highest number of cases were reported from Missouri and Arkansas. We report the geographic expansion of E. ewingii ehrlichiosis and the continued public health challenge of clarifying clinical manifestations of this infection. Clinician education will be essential to implement molecular assays to properly diagnose E. ewingii infection in patients and gain a better understanding of the epidemiology of this emerging disease.