Infant botulism in 1931. Discovery of a misclassified case

Infant botulism: an underestimated threat

Infant botulism (IB) is defined as a potentially life-threatening neuroparalytic disorder affecting children younger than 12 months. It is caused by ingestion of food or dust contaminated by Clostridium botulinum spores, which germinate in the infant's large bowel and produce botulinum neurotoxin. Although the real impact of IB is likely underestimated worldwide, the USA has the highest number of cases. The limited reporting of IB in many countries is probably due to diagnostic difficulties and nonspecific presentation. The onset is usually heralded by constipation, followed by bulbar palsy, and then by a descending bilateral symmetric paralysis; ultimately, palsy can involve respiratory and diaphragmatic muscles, leading to respiratory failure. The treatment is based on supportive care and specific therapy with Human Botulism Immune Globulin Intravenous (BIG-IV), and should be started as early as possible. The search for new human-like antibody preparations that are both highly effective and well tolerated has led to the creation of a mixture of oligoclonal antibodies that are highly protective and can be produced in large quantities without the use of animals. Ongoing research for future treatment of IB involves the search for new molecular targets to produce a new generation of laboratory-produced antitoxins, and the development of new vaccines with safety and efficacy profiles that can be scaled up for clinical use. This narrative literature review aims to provide a readable synthesis of the best current literature on microbiological, epidemiological and clinical features of IB, and a practical guide for its treatment.

Seven-Year Case-Control Study in California of Risk Factors for Infant Botulism

OBJECTIVE

To ascertain possible risk factors for infant botulism, the intestinal infectious form of human botulism, in the years immediately following its initial recognition in California in 1976.

STUDY DESIGN

Parents of 159 California laboratory-confirmed cases of infant botulism from 1976 to 1983 and 318 healthy controls were interviewed using a comprehensive (>300 factors) questionnaire. "Neighborhood controls" (n = 184) were matched on date of birth, sex, race/ethnicity, and neighborhood of residence. "County controls" (n = 134) were matched only on date of birth, sex, and county of residence. Age-stratified bivariate and multivariate conditional logistic regression analyses were performed using SAS.

RESULTS

All cases required hospitalization. Bivariate analyses identified several risk factors that in multivariate analyses were not significant. In multivariate analyses, risk factors differed with stratification by age. For the ≤2 month-old neighborhood controls comparison, birth order >1, cesarean delivery, ≤1 bowel movements (BMs) per day, and windy residence area were associated with illness hospitalization, and for the county controls comparison, only pacifier use was associated. For the <2 month-old neighborhood controls comparison, <1 bowel movements (BMs) per day, cesarean delivery, birth order >1, and windy residence area were associated with illness hospitalization, and for the county controls comparison, pets in the home was an additional risk factor.

CONCLUSIONS

With the exception of the ≤2-month-old county controls group, slower intestinal transit time (≤1 BM/d) was associated with illness. Otherwise, our case-control investigation identified few physiologic, environmental, and maternal factors associated with infant botulism hospitalization in California.

Descriptive Epidemiology of Infant Botulism in California: The First 40 Years

OBJECTIVE

To ascertain the descriptive epidemiology of infant botulism, the flaccid paralysis that results when neurotoxigenic Clostridium species produce botulinum toxin (BoNT) in the infant colon, in its first 40 years following initial recognition in California in 1976.

STUDY DESIGN

Cases were defined by laboratory identification of BoNT and/or neurotoxigenic Clostridium species in patients' feces. Parents were interviewed using a structured questionnaire. Descriptive epidemiologic characteristics were compared between 1976-1996 and 1997-2016.

RESULTS

From 1976-2016, 1345 cases of infant botulism occurred in 45 of 58 California counties (6.5 cases/100 000 live-births/year) caused by BoNT types A, B, Ba, Bf, and F; 88% of cases were ≤6 months of age and 51% were female. Cases were white (84.2%), Asian (8.9%), other races (3.8%), and African American (2.8%); 29.4% of cases were Hispanic. More than 99% of cases were hospitalized. Case occurrence peaked in summer-fall. Of 8 designated geographic regions, the Central Coast counties had 3 times the statewide incidence in both 20-year time periods. Breast-fed patients (83%) were more than twice as old at onset as formula-fed patients (median, 4.4 vs 1.7 months, respectively; P < .001). BoNT/A cases were older at onset than BoNT/B cases (median, 3.8 vs 2.9 months, respectively; P < .001).

CONCLUSIONS

Comprehensive continuous surveillance of infant botulism for 40 years in a large, diversely populated state identified fundamental epidemiologic characteristics of this uncommon illness. Unusual features included greater than 99% case hospitalization, absence of male preponderance, and a distinctive age distribution.

AbobotulinumtoxinA: A 25-Year History

During the late 1960s and early 1970s, Alan Scott showed that intramuscular injections of botulinum toxin (BoNT) corrected nonaccommodative strabismus without resorting to surgery. The UK doctors who trained with Scott soon realized the significant potential offered by BoNT type A as a therapeutic option for several difficult-to-treat diseases. This led to a collaboration between these pioneering clinicians and the Centre for Applied Microbiology and Research at Porton Down, United Kingdom, and, in turn, to the development and commercialization of abobotulinumtoxinA as Dysport (Dystonia/Porton Down; Ipsen Biopharm Ltd., Wrexham, UK). Dysport was approved in Europe for the treatment of specific dystonias in December 1990 and now has marketing authorizations in 75 countries. Since then, the use of BoNT in therapeutic and aesthetic indications has grown year-on-year, and continues to expand well beyond Scott's initial aim. For example, ongoing trials are assessing potential new indications for BoNT-A, including acne and psoriasis. Furthermore, a growing number of other BoNT products, often termed "biosimilars," together with innovative formulations of well-established BoNT types, are likely to reach the market over the next few years. This review focuses on the history of Dysport to mark the 25th anniversary of its first launch in the United Kingdom.

Infant botulism: review and clinical update

Botulism is a rare neuromuscular condition, and multiple clinical forms are recognized. Infant botulism was first identified in the 1970s, and it typically occurs in infants younger than 1 year of age who ingest Clostridium botulinum spores. A specific treatment for infant botulism, intravenous botulism immunoglobulin (BIG-IV or BabyBIG®), was developed in 2003, and this treatment has substantially decreased both morbidity and hospital costs associated with this illness. This article will review the pathogenesis of infant botulism as well as the epidemiology, clinical manifestations, diagnosis, and treatment of this condition.

Detection of C. botulinum types in honey by mPCR

The aim of this study was to determine the prevalence of Clostridium botulinum in honey samples using conventional methods and multiplex PCR (mPCR). A total number of 150 honey samples were randomly collected from apiaries, retail shops, weekly open bazaars, and supermarkets in Samsun, Turkey. Of 150 honey samples, 4 (2.6%) were positive for the botulinum neurotoxin gene by mPCR analysis. A total of 4 C. botulinum isolates were obtained from the mPCR positive samples, of which 3 were type A and 1 was type B. No samples were positive regarding the type E and type F neurotoxin genes. This is the first report of type A and type B spores of C. botulinum being detected and isolated in Turkey. This study revealed that some honey samples may present a potential hazard for food borne and infant botulism.

Infant botulism: 20 years' experience at a single institution

Admissions from January 1, 1985, to December 31, 2005, with the diagnosis of infant botulism were reviewed to describe the clinical presentation, course, outcome, and changes related to the availability of botulism immune globulin treatment. Botulism diagnoses were confirmed by the finding of toxin or Clostridium botulinum organisms in stool samples (type A, 14; type B, 25; type not noted, 5). Twenty-four patients were admitted from 1985-1994 and 20 from 1995-2004. Infants in the two decades were similar in age, demographics, and presenting features. Ventilator support was needed in 13 of 24 (54%) in 1985-1994 and in 15 of 20 (75%) in 1995-2005; 43 required nasogastric feeding. Seventeen patients were treated with botulism immune globulin. Length of stay was shorter in infants treated with botulism immune globulin (13.5 vs 23 days, P = .009), with a trend toward reduced need for nasogastric feeding and in shorter duration of tracheal intubation. All patients recovered fully. Even with the availability of botulism immune globulin, meticulous supportive care remained essential for recovery.

Infant botulism: a review in South Australia (1980-89)

Between March 1980 and March 1989 there were six identified cases of infant botulism. The presenting symptoms were predominantly poor feeding, lethargy and constipation, and the presenting signs were predominantly hypotonia, weak gag reflex and respiratory difficulty. All required intensive care and prolonged hospital stays. Recovery was eventually complete in all cases. Infant botulism is an uncommon condition but early recognition with adequate intensive care usually results in complete recovery.

Infant botulism: a case series and review of the literature

Little has been written about infant botulism in the emergency medicine literature, despite increasing references in the pediatric journals. We describe three cases diagnosed at The Children's Hospital in Denver, Colorado, over an 8-month period. A review of the literature follows, to discuss the clinical manifestations, differential diagnosis, diagnostic workup and treatment of the disease.

Quantitation of Clostridium botulinum organisms and toxin in the feces of an infant with botulism

A 4-month-old boy presented with symptoms and signs characteristic of infant botulism. Examination of feces revealed Clostridium botulinum type B and type B toxin. The numbers of C. botulinum and the amount of toxin in feces were measured throughout the 4-week period in hospital. The maximum numbers and amounts were detected in a fecal specimen collected 16 days after admission: this contained 8.4 X 10(6) C. botulinum type B colony-forming units and 61,440 mouse 100% lethal doses of type B toxin per g (wet weight) of feces. This latter figure is the highest fecal toxin titer reported yet for a case of infant botulism. By day 16, however, substantial improvement in the patient's clinical condition had occurred. This suggests that initiation of recovery from infant botulism is not necessarily preceded by a reduction in the numbers of C. botulinum organisms and the quantity of toxin in the gut.