Despite a low incidence of botulism in the industrialized world some cases occasionally occur in Germany after eating contaminated food. Because botulism is rarely seen, most physicians are unfamiliar with its early recognition and treatment. However, immediate intensive care treatment is important. We report the case of a previously healthy 54-year-old female who developed signs of botulism after eating vacuum packed smoked fish and developed severe respiratory insufficiency with difficult carbon dioxide elimination in the days following.