A previously healthy infant presented with a 10-day history of constipation followed by feeding difficulty and progressive bulbar and facial weakness. Examination showed sluggish pupillary light reflexes and evolving symmetric descending flaccid paralysis, leading to transfer to a pediatric intensive care unit for respiratory support. Initial investigations included blood cultures, cerebrospinal fluid analysis, viral testing, and magnetic resonance imaging of the brain and spine, all of which showed no evidence of infection or structural abnormality.
Fecal samples were obtained via rectal washout and were submitted to a reference laboratory for culture and identification of botulinum neurotoxin–producing organisms. While awaiting laboratory confirmation, bedside nerve conduction studies were performed on days 3 and 5 of hospitalization. These studies demonstrated reduced compound muscle action potential amplitudes with facilitation on repetitive high-frequency stimulation, consistent with infant botulism. On day 4 of hospitalization, clinicians administered equine-derived botulinum antitoxin heptavalent, the only antitoxin immediately available in Ireland, and requested Botulism Immune Globulin Intravenous [Human] through the Infant Botulism Treatment and Prevention Programme.
Laboratory confirmation was obtained on day 7, when Clostridium botulinum type B was isolated from fecal cultures using enrichment media and polymerase chain reaction assays targeting botulinum neurotoxin genes. Botulism Immune Globulin Intravenous [Human] was administered later that day. The infant experienced no adverse reactions to either antitoxin. Following a brief febrile episode with respiratory secretions treated empirically with intravenous antibiotics, neurologic recovery progressed, with return of gag reflexes by day 10 and successful extubation by day 13. The infant was discharged home on day 17, with feeding ability and cry fully restored at follow-up 27 days after presentation.
Public health authorities were notified based on clinical suspicion before laboratory confirmation, allowing for early initiation of a multidisciplinary investigation. Despite extensive environmental and food testing, no definitive exposure source was identified. “This case underscores the value of rapid clinical recognition, early investigation and treatment, and coordinated public health action in the management of rare but high-consequence conditions such as [infant botulism],” noted the lead author John Gannon of the Department of Public Health, Health Service Executive, Dublin, Ireland, and colleagues.
The researchers reported no conflicts of interest.
Source: Clinical Case Reports
