This case-report highlights: i) the difficulty of IB diagnosis as it is a rare syndrome with subclinical onset, ii) the need for an accurate training for physicians involved in IB management, iii) the efficacy and safety of TEqA in IB treatment, iv) homemade honey is not the only cause of IB

Bruna Auricchio

Dilettta Sabatini

Fabrizio Anniballi

GRASSI, Maria Caterina

Laura Papetti

LONATI, DAVIDE

PROPERZI, Enrico

English

Archivio della ricerca- Università di Roma La Sapienza

C A S E R E P O R TA case of infant botulism in a 4-month-old babyD. Sabatini1, L. Papetti2, D. Lonati3, F. Anniballi4, B. Auricchio4, E. Properzi2and M.C. Grassi1From the 1Emergency Toxicology and Poison Control Centre Unit, Umberto I Policlinico of Rome and SapienzaUniversity of Rome, Italy, 2Department of Pediatrics, Sapienza University of Rome, Italy, 3Poison ControlCentre and National Toxicology Information Centre, Toxicology Unit, IRCCS Maugeri Foundation, Pavia, Italyand 4Department of Veterinary Public Health and Food Safety, National Reference Centre for Botulism, IstitutoSuperiore di Sanita`, Rome, ItalyAddress correspondence to M.C. Grassi, Emergency Toxicology and Poison Control Centre Unit, Umberto I Policlinico of Rome, Department of Physiology andPharmacology “V. Erspamer” - Sapienza University of Rome, School of Medicine, Piazzale Aldo Moro 5, 00185 Rome, Italy. email: caterina.grassi@uniroma1.itLearning point for cliniciansThis case report highlights: (i) the difficulty of infantbotulism (IB) diagnosis as it is a rare disease, (ii) the effi-cacy and safety of trivalent equine antitoxin in IB treat-ment, (iii) honey is not the only cause of IB and (iv) theneed for physician training to recognize and diagnose IB.Case presentationA 4-month-old baby (7 kg) was admitted to the PediatricDepartment for constipation, feeding difficulties, weak cry, leth-argy and weak muscular body control. Symptoms of infantbotulism (IB) appeared 1 month before the admission, afterhexavalent vaccine administration, with a slow and progressiveevolution. The baby has become lethargic, with blunted facialexpression and weak cry. Seven days before admission hestarted refusing breast milk. Clinical history revealed noperinatal or delivery complications and the baby was normal fordevelopment and growth (50th percentile). On admission thebaby was fully conscious and the initial exam confirmed gener-alized but moderate hypotonia, bilateral ptosis and strabismus.The tendon reflexes remained symmetric. Pediatricians sus-pected a cerebral infectious disease; therefore, dexamethasoneceftriaxone, acyclovir and dextrose were administered. Thelaboratory and radiological exams showed no abnormalities aswell as cerebrospinal analysis; viral and metabolic tests werenormal. Clinical course improved quickly and the baby was dis-charged after 1 week. Since constipation and bilateral ptosiswere not completely resolved, a follow-up visit was planned in10 days. At the time of follow-up symptoms were still observed.Therefore, the baby was re-hospitalized for further examin-ation. On the second day, the clinical condition worsened inthat oxygen desaturation, generalized and severe hypotoniaand non-reactive bilateral mydriasis appeared. The babyrefused breastfeeding and enteral nutrition was started.Electromyography confirmed presynaptic block. Given the clin-ical scenario, IB was suspected.Clinical samples were submitted for laboratory confirmationat the National Reference Centre for Botulism and Clostridiumbotulinum type A was detected in rectal swabs and enema viareal-time Polimerase Chain Reaction (PCR). No botulinum neuro-toxins (BoNTs) were detected in enema. Spores excretion becamenegative 4 days after the laboratory confirmation. History re-vealed that the child had ingested honey 5 days prior to the onsetof symptoms. However, analysis of leftover honey resulted nega-tive for C. botulinum spores. The patient was transferred to thePediatric Intensive Care Unit. Upon indication of Rome and PaviaPoison Control Centres, trivalent equine antitoxin (BotulismAntitoxin Behring: 750 IU-anti-A, 500 IU-anti-B, 50 IU-anti-E/ml;10 ml/kg/iv) was administered. Clinical conditions improved 48 hlater and the baby was moved to the Pediatric Department after10 days. Enteral nutrition was required for 3 weeks. The babywas discharged without sequelae after 1 month.VC The Author 2015. Published by Oxford University Press on behalf of the Association of Physicians.All rights reserved. For Permissions, please email: journals.permissions@oup.com1QJM: An International Journal of Medicine, 2015, 1–2doi: 10.1093/qjmed/hcv061Advance Access Publication Date: 13 March 2015Case report QJM Advance Access published March 30, 2015by guest on April 27, 2015Downloaded from DiscussionIB is a life-threatening disease that results from absorption ofBoNTs produced in situ by clostridia that colonize the intestinallumen of infants below 1 year of age.1 Colonization occurs be-cause normal bowel florae that could compete with clostridiahave not been fully established.2 BoNTs cause muscle flaccidparalysis through presynaptic blockade of acetylcholine re-lease.1 The clinical onset is insidious and characterized by con-stipation, weak cry, difficulty in breastfeeding, poor muscletone and finally paralysis of the respiratory muscles. The diag-nosis is frequently delayed. The identified risk’s factors for IBare honey, and spores coming from telluric environments orherbal infusion (i.e. dust, chamomile).2 IB is a rare but generallyreversible disease, and antidotal therapy is required in selectedcases.3 Different antitoxin formulations are available for botu-lism.3,4 The treatment with trivalent equine antitoxin showedno acute or delayed adverse reactions and represents an effect-ive method for rapidly reversing IB.3,5 In USA, Baby-BIG, human-derived botulism antitoxin, is the antitoxin of choice for IB’streatment, but the high cost limits its use in many countries.6 Inother countries, equine antitoxin is currently used and con-sidered safe and effective.3,5Despite honey ingestion is among the most common causeof IB, this was not the cause. We hypothesize that the probablesource of C. botulinum spores was the dust settled on the clothesof baby’s father who worked as a bricklayer and was use to cra-dle the baby in his arms coming back home.In conclusion, this case report suggests that diagnosis of IBmust be considered even when no history of honey intake is re-ported, and also highlights the need for physician to receive ad-equate training to recognize and diagnose IB.Conflict of interest: None declared.References1.Fenicia L, Anniballi F. Infant botulism. Ann Ist Super Sanita2009; 45:134–46.2.Brook I. Infant botulism. J Perinatol 2007; 27:175–80.3.Lonati D, Fenicia L, Petrolini V, Giampreti A, Anniballi F,Vecchio S,et al. Dose adjustment of trivalent equine anti-toxin in the treatment of infant botulism. Clin Toxicol 2012;50:317–8.4.Anniballi F, Lonati D, Fiore A, Auricchio B, De Medici D,Locatelli CA. New targets in the search for preventive andtherapeutic agents for botulism. Expert Rev Anti Infect Ther 2014;12:1075–86.5.Vanella de Cuetos EE, Fernandez RA, Bianco MI, Sartori OJ,Piovano ML, Luquez C, et al. Equine botulinum antitoxin for thetreatment of infant botulism. Clin Vaccine Immunol 2011; 18:1845–9.6.Arnon SS, Schechter R, Maslanka SE, Jewell NP, Hatheway CL.Human botulism immune globulin for the treatment of infantbotulism. N Engl J Med 2006; 354:462–71.2 | QJM: An International Journal of Medicine, 2015, Vol. 0, No. 0by guest on April 27, 2015Downloaded from 

A case of infant botulism in a 4-month-old baby

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A case of infant botulism in a 4-month-old baby

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