A previously healthy 5-month-old male infant was admitted to a
Massachusetts hospital in November 1983 with progressive lethargy
and
loss of developmental milestones over 3 weeks, constipation for 12
days, and poor suck and feeding. He had been breast-fed, and
bottled
foods were added at the age of 3 months. On examination, the child
was generally hypotonic with flaccid extremities, no head control,
and
no suck or Moro reflexes. He was alert, able to smile, and had no
oculomotor weakness. An electromyogram revealed a post-tetanic
facilitation pattern after stimulation at 50 Hz, compatible with
infant botulism. He was initially treated with intravenous
hydration
and saline enemas. Naso-gastric feedings were begun on the fourth
hospital day, and he improved gradually thereafter. Type B
botulinal
toxin and Clostridium botulinum were identified in a stool specimen
by
the Massachusetts State Laboratory.
Reported by DG Sidebottom, MD, Children's Hospital, Boston, JP
Reardon, MD, MB Holmes, NJ Fiumara, MD, State Epidemiologist,
Massachusetts Dept of Public Health; Enteric Diseases Br, Div of
Bacterial Diseases, Center for Infectious Diseases, CDC.
Editorial Note
Editorial Note: Infant botulism, in contrast to foodborne botulism
resulting from ingestion of preformed toxin, is caused by C.
botulinum
toxin produced in and absorbed from the gastrointestinal tract,
leading to neurologic manifestations. This report represents the
first case of infant botulism identified in Massachusetts and the
second from the New England states; the first reported case
occurred
in 1983 in Connecticut. Infant botulism was first identified in
1976;
four states--California, Texas, Pennsylvania, and
Tennessee--reported
cases that year. To date, 36 states in all geographic regions,
including Alaska and Hawaii, have identified cases. Between 1976
and
1983, 395 cases were reported to CDC. Patients' ages ranged from 2
to
38 weeks, and 204 (52%) were male; most were hospitalized, and 11
died. Type A botulinal toxin was identified in 50% of the cases;
type
B, in 49%; and types F and B/F, in one case each.
A case-control study performed by the California Department of
Health Services in 1976-1978 showed that infants with type B
botulism
were more likely than controls to have been fed honey, and type B
spores were identified in implicated honey samples (1). This is
the
only exposure that is a clearly defined risk factor for cases of
infant botulism, and CDC has recommended that honey not be fed to
infants under 1 year of age (2). In a 1976-1980 epidemiologic
study
of infant botulism cases reported through CDC's surveillance system
from states other than California, 96 infant botulism patients were
compared with infants in the general population; infant botulism
patients tended to have higher birth weights, and their mothers
tended
to be older and better educated (3). Seventy percent of the
botulism
patients were predominantly breast-fed.
For patients in whom the diagnosis of infant botulism is
considered, physicians should collect stool specimens for toxin
testing and culture and should contact their state health
departments
for processing specimens. Treatment is mainly supportive, with
gradual recovery in most cases. Enemas may be given to help
eliminate
toxin from the gastrointestinal tract. The roles of botulinal
antitoxin and antimicrobials in treatment are unclear.
References
Arnon SS, Midura TF, Damus K, Thompson B, Wood RM, Chin J.
Honey
and other environmental risk factors for infant botulism. J
Pediatr 1979;94:331-6.
CDC. Honey exposure and infant botulism. MMWR 1978;27:249-50,
255.
Morris JG, Snyder JD, Wilson R, Feldman RA. Infant botulism in
the United States: an epidemiologic study of cases occurring
outside of California. Am J Public Health 1983;73:1385-8.
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