A 7–month–old Caucasian male was admitted to a hospital in central California due to complaints of poor feeding. There was remote history of choking on a plastic bead which was removed by mother. Five days prior to admission he was noted to have difficulty breastfeeding and decreased activity. Family denied fever and endorsed constipation. They had recently moved to a new house in a rural area near a large corn field. The patient and siblings were unimmunized. Initially there was concern for retained foreign body or retropharyngeal abscess. He received neck radiographs and CT scan which were normal. Lab work showed a mild leukocytosis and elevated platelet count. He was started on broad spectrum antibiotics but developed new respiratory distress. At this point there was also concern for atypical infection such as epiglottitis or diphtheria given his unimmunized status. He was transferred to our tertiary care facility for further evaluation. His initial exam was significant for ptosis, hypotonia, and difficulty handling secretions. Shortly after arrival the patient had an episode of apnea and bradycardia that required chest compressions, intubation, and transfer to the intensive care unit. Due to history and physical exam, we suspected botulism. He received one dose of baby botulism immune globulin (baby BIG) and stool was positive for botulism toxin type A. The patient improved, was extubated after 8 days, and was feeding well with good muscle strength at the time of discharge.
Infantile botulism occurs when an infant ingests Clostridium botulinum spores which germinate in the intestinal tract and release neurotoxins that block acetylcholine release. It is a rare disorder with an average of 71 cases per year in the United States, of which half occur in California. Recognized risk factors are exposure to honey or soil. Clinical diagnosis is based on classic findings of constipation, hypotonia, and a weak cry. Definitive diagnosis requires indirect detection of toxin in stool, which is done only by state health departments or the CDC and can take several days. Electromyogram studies also support the diagnosis, but can be normal in early disease. Treatment is therefore often initiated based on clinical suspicion alone. Baby BIG should be given as soon as possible to inactivate unbound toxin. Most patients have prolonged hospital stays requiring intubation and intensive supportive care. Infant botulism has also been implicated in cases of Sudden Infant Death Syndrome. Prognosis is generally good if the disease is recognized.
This case illustrates how infantile botulism is often confused with other diagnoses. When accepting transferred patients, hospitalists must reassess patients and reconsider the differential diagnosis. An up to date literature review is presented to improve recognition and patient outcomes.