Case Presentation: A 14-year-old female began experiencing acute progressive ocular involvement with ptosis and esotropia, bulbar weakness leading to respiratory failure, and upper extremity weakness after forearm open fracture and surgical repair complicated by wound infection. Initial differential diagnosis included Guillain-Barre syndrome, myasthenia gravis, botulism, and other toxin-mediated diseases. Median nerve motor response was mildly reduced which improved after short exercise. Low frequency repetitive nerve stimulation (RNS) in a clinically weak APB muscle showed decremental response while EMG showed non-irritable myopathic changes. High frequency RNS of the right median nerve did not demonstrate an incremental response. These findings heightened suspicion of myasthenia gravis onset in a crisis. However, because these electrodiagnostic findings could not distinctly rule out presynaptic NMJ disorder, the alternative diagnosis of dirt-contaminated botulism wound infection remained possible. Wound cultures and serum toxin assay later demonstrated active botulism. To ensure broad treatment coverage, she was treated with the heptavalent botulinum antitoxin as well as intravenous immunoglobulins and improved, eventually being discharged 77 days after hospital presentation.