History: A 30-day old, ex full-term male presented to the Pediatrician (PCP) office for three days of congestion, increased secretions, and low oral intake suspicious of bronchiolitis. During the evaluation, the infant became apneic and cyanotic, with oxygen saturations of 70% thought to be due to mucus plugging. The PCP initiated CPR for respiratory failure and called 911. In the Emergency Department, the patient had blood and urine cultures, a respiratory viral panel, and started antibiotics. Parents denied significant medical history and confirmed that his growth and development were normal.
Physical examination was significant for initial hypothermia with a temperature of 94.2 F. He had mild tachycardia but stable blood pressures (pulse 156, BP 93/52) with palpable pulses. On respiratory exam, his oxygen saturation was 94% with tachypnea (rate 47), mild retractions, and no grunting on high flow nasal cannula 10lpm with 50% FiO2. Neurological exam was significant for decreased tone, and his response to tactile stimulation was minimal. Labs showed a venous pH 7.017 with pCO2 96, white blood cell count of 35,000, creatinine of 0.6, and glucose of 180. A CXR showed bilateral infiltrates concerning for pneumonia. He was admitted to the Pediatric Intensive Care Unit (PICU) for further care with the initial diagnosis of acute respiratory failure due to sepsis or bronchiolitis. On arrival to the PICU, he required support with non-invasive SiPAP via nasal mask. VBGs improved over the day. On hospital day 2, the patient had a second episode of apnea and became bradycardic. He was intubated and stabilized. Aside from his fluctuating temperature, his vitals remained within normal limits. Infectious labs and cultures were negative for infection, including CSF studies. Because the patient did not require sedation, and his mental status continued to worsen, a head ultrasound was obtained, which was unremarkable.
Further history revealed the patient had constipation for the last 7-10 days, and mom had given corn-syrup to help his symptoms. A stool sample was collected via enema and sent for clostridium botulinum evaluation. The process to obtain Botulism Immune Globulin began, and it was administered on hospital day 3. The patient was extubated on hospital day 9 and eventually discharged on day 20 with full recovery.
Discussion: Infant botulism is a rare but important cause of critical illness in pediatrics. This patient's presentation was dramatic, with apnea requiring intubation, which initially led to evaluation for bronchiolitis and bacterial sepsis. Subsequently, the patient's neurologic weakness became more obvious, and suspicion grew for infant botulism. This patient's stool sample resulted positive for botulinum toxin serotype B. Providers need to have a high index of suspicion in any infant with low tone and a history of constipation with or without clear exposure to honey as transmission can occur in other household products like corn syrup. Moreover, soil and dust are theoretical sources of spores, although this has not been proven by any control studies (CDC). When offering advice to new parents, one must always keep in mind that it is crucial to discuss the detrimental sequelae honey and household products like corn syrup can have on an infant.
