A case of Infantile Botulism

A report describes a case of a 5-week-old girl who presented with the complaint of decreased activity and feeds, poor suck, weak cry and lethargy for three days. 

She had a history of oral thrush for the past two weeks which was unresponsive to nystatin, had poor weight gain since birth, and had microcephaly. There was no history of fever, vomiting, diarrhea, cough, congestion, increased work of breathing, or sick contacts. The patient had the last bowel movement 2 days before the presentation. She was feeding on both the breast milk and the formula.

Screening revealed alpha thalassemia trait. Her vitals were: 36.3°C temperature, 168 beats/min heart rate, 60% oxygen saturation on room air, and 32 breaths/min respiratory rate. 

Physical examination revealed an ill-appearing, lethargic infant with a nearly absent cry, sunken anterior fontanelle, 34.5 cm head circumference (1st percentile), reactive pupils, no ophthalmoparesis, dry mucous membranes and weak pulses with a capillary refill >5 seconds, poor skin turgor, and mottling. Appendicular and axial hypotonia were present with a marked head lag; however, her Patellar, biceps, and brachioradialis reflexes were absent, and the suck reflex was weak. Gag reflex was present.

Lab investigations revealed Serum glucose of 268 mg/dl, pH as 7.27, and urine glucose of 250 mg/dl. Cerebrospinal fluid (CSF) comprised 125 total nucleated cells/mcL, 287,000 erythrocytes/mcL, 74 mg/dL glucose, 796 mg/dL protein, and negative CSF multiplex PCR and CSF HSV PCR. 

Chest X-ray revealed right basilar atelectasis, while Head CT without contrast was normal. 

The patient received continuous positive airway pressure that improved her saturation. On day 2 of hospitalization, the infant required intubation due to increasing apneic events. She received human-derived botulism immune globulin on the fourth day of admission due to the suspicion of infantile botulism, which caused a gradual improvement in tone.

Given the infant's lack of stooling, a stool test for direct toxin analysis and culture came back positive for botulinum toxin type A by the fifth day of hospitalization. Electromyography performed before revealed low compound muscle action potential amplitudes at baseline that decreased with four repetitive stimuli at a frequency of 2 Hz and faster rates of repetitive stimulation representing facilitation, backing the clinical diagnosis of botulism. 

The patient was extubated within days of receiving botulism immune globulin but required frequent suctioning for secretions. She received a discharge on nasogastric tube feeds that remained for approximately three weeks after botulism immune globulin administration.

Authement MC, Jones BM, Kahoud RJ, et al. From Rarity to Recognition: Infantile Botulism and the Broad Spectrum of Differential Diagnoses. Case Rep Pediatr. 2024 Feb 26;2024:4647591. doi: 10.1155/2024/4647591. PMID: 38440049; PMCID: PMC10911872.