A four-month old infant girl presented at the ED by her parents in respiratory distress, an intermittent, weak cry, and was minimally responsive. The infant was noticeably drooling and the mother mentioned the child had been fussy and drooling more than usual over the past two days, but likely this was due to the fact that the infant started teething last week. The mother, father, and 2-year-old brother were all healthy and there was no concern for access to medications or household products.
Vital signs: Vital signs: HR 140, BP 89/52, T 36.4 C, RR 53, SpO2 100% on NRB (80% on RA), blood glucose 120
Eyes: pupils equal and reactive
Cardiac: regular rate and rhythm, no murmurs
Pulm: poor inspiratory effort, clear lung sounds
Abd: soft, non-tender, non-distended
Extrem: moving extremities with poor effort
Neuro: minimally responsive, withdrawing from pain
Skin: no rashes
ED course: The child was emergently intubated for respiratory failure. A broad lab and imaging work up were obtained including cultures, chest x-ray, and head CT were obtained. Her chest x-ray was suggestive of pneumonia - so Ceftriaxone was given and she was admitted to the PICU for further management.
His head CT and blood cultures were negative. Additional workup, including a brain and spine MRI, lumbar puncture, and urine cultures were also negative. A viral panel was positive for rhino/enterovirus. She initially was diagnosed with flaccid paralysis secondary to Enterovirus. However, it was discovered that the patient’s father worked in construction and was frequently exposed to large amount of freshly dug up soil, which raised the suspicion for botulism, so she was started on anti-botulinum toxin and demonstrated improvement in his clinical status. On hospital day 9 her C. botulinum toxin study returned positive. She was extubated on hospital day 14 and continued to improve, until she was discharged on hospital day 19 with a normal neurological exam. She has followed up several times over the last few years and continued to do well.
1. The parents ask you, “What is Clostridium botulinum?”
2. How did our baby get infected?
3. Given your answer in “2” above, the parents are concerned about any exposures from dad. How do you mitigate their fears?
4. Explain how C. botulinum caused the infant’s symptoms.