Infant botulism. Epidemiological, clinical, and laboratory aspects

Case report: Aberrant fecal microbiota composition of an infant diagnosed with prolonged intestinal botulism

BACKGROUND

Intestinal botulism is primarily reported in small babies as a condition known as infant botulism. The condition results from the ingestion of environmental or foodborne spores of botulinum neurotoxin (BoNT) producing Clostridia, usually Clostridium botulinum, and subsequent spore germination into active botulinum neurotoxinogenic cultures in the gut. It is generally considered that small babies are susceptible to C. botulinum colonization because of their immature gut microbiota. Yet, it is poorly understood which host factors contribute to the clinical outcome of intestinal botulism. We previously reported a case of infant botulism where the infant recovered clinically in six weeks but continued to secrete C. botulinum cells and/or BoNT in the feces for seven months.

CASE PRESENTATION

To further understand the microbial ecology behind this exceptionally long-lasting botulinum neurotoxinogenic colonization, we characterized the infant fecal microbiota using 16S rRNA gene amplicon sequencing over the course of disease and recovery. C. botulinum could be detected in the infant fecal samples at low levels through the acute phase of the disease and three months after recovery. Overall, we observed a temporal delay in the maturation of the infant fecal microbiota associated with a persistently high-level bifidobacterial population and a low level of Lachnospiraceae, Bacteroidaceae and Ruminococcaceae compared to healthy infants over time.

CONCLUSION

This study brings novel insights into the infant fecal composition associated with intestinal botulism and provides a basis for a more systematic analysis of the gut microbiota of infants diagnosed with botulism. A better understanding of the gut microbial ecology associated with infant botulism may support the development of prophylactic strategies against this life-threatening disease in small babies.

Infant Botulism: Checklist for Timely Clinical Diagnosis and New Possible Risk Factors Originated from a Case Report and Literature Review

Infant botulism is a rare and underdiagnosed disease caused by BoNT-producing clostridia that can temporarily colonize the intestinal lumen of infants less than one year of age. The diagnosis may be challenging because of its rareness, especially in patients showing atypical presentations or concomitant coinfections. In this paper, we report the first infant botulism case associated with Cytomegalovirus coinfection and transient hypogammaglobulinemia and discuss the meaning of these associations in terms of risk factors. Intending to help physicians perform the diagnosis, we also propose a practical clinical and diagnostic criteria checklist based on the revision of the literature.

Genomic Characterization of Newly Completed Genomes of Botulinum Neurotoxin-Producing Species from Argentina, Australia, and Africa

Botulinum neurotoxin-producing clostridia are diverse in the types of toxins they produce as well as in their overall genomic composition. They are globally distributed, with prevalent species and toxin types found within distinct geographic regions, but related strains containing the same toxin types may also be located on distinct continents. The mechanisms behind the spread of these bacteria and the independent movements of their bont genes may be understood through examination of their genetic backgrounds. The generation of 15 complete genomic sequences from bacteria isolated in Argentina, Australia, and Africa allows for a thorough examination of genome features, including overall relationships, bont gene cluster locations and arrangements, and plasmid comparisons, in bacteria isolated from various areas in the southern hemisphere. Insights gained from these examinations provide an understanding of the mechanisms behind the independent movements of these elements among distinct species.

Flaccid paralysis in an infant associated with a dirty wound and application of honey

An infant, who was born preterm at 36 weeks, presented with fever and ulcer at umbilical region which progressed to necrotising fasciitis of anterior abdominal wall. He was treated with intravenous penicillin, intravenous cloxacillin and local application of medicated honey. Subsequently, he required wound debridement. Postoperatively, he required prolonged invasive ventilation due to poor respiratory effort which was associated with hypotonia and areflexia. Nerve conduction study revealed absent responses. The diagnosis of infant botulism was made based on the clinical presentation, nerve conduction study and his clinical progress. Botulinum immunoglobulin was not available. He was treated with intravenous immunoglobulin and oral pyridostigmine. He was successfully extubated after 37 days, and currently the patient is doing well.

Parents' and primary healthcare practitioners' perspectives on the safety of honey and other traditional paediatric healthcare approaches

BACKGROUND

Traditional and complementary healthcare approaches (TCA) are widely used for children, often because of perceived safety. Honey is a traditional remedy for upper respiratory tract symptoms in infants. Health officials currently advise limiting honey use because of the risk of botulism.

OBJECTIVE

This paper discusses honey as a traditional healthcare approach for children in a multi-ethnic community, and parents' and primary healthcare practitioners' (PHPs) perceptions of its safety.

DESIGN

As part of a larger study exploring beliefs about TCA, this paper focuses on perceived safety and use of honey, using data extracted for detailed analysis. Eleven parent focus groups (n= 92) and 30 interviews with PHPs were conducted. Qualitative data analysis used the Framework approach.

SETTING

London Boroughs of Brent and Harrow

RESULTS

TCA, particularly home remedies, dietary and religious approaches were popular for children. Honey was a particularly common TCA, reportedly used by 27 (29%) parents for their children. Honey was believed to be traditional, acceptable, accessible, natural and safe. It was most commonly used for respiratory tract symptoms and administered with hot water and lemon juice. PHPs were more concerned about the safety of TCA than parents. Almost half (40%) of PHPs mentioned the use of honey for children, few perceived it as a 'treatment' or were concerned about botulism. Others were aware of the risks and some reported challenges in communicating risk to parents.

CONCLUSION

TCA are commonly used for children, honey in particular for respiratory tract symptoms. Parents and some PHPs appear unaware of the risk of botulism from honey use in infants. Healthcare practitioners should ask routinely about the use of honey and other TCA, and consider different parental belief systems in ethnically diverse populations. Further research is required on the use and efficacy of honey for infants, to raise awareness of its benefits and risks.

Physician and parent response to the FDA advisory about use of over-the-counter cough and cold medications

OBJECTIVE

The aim of this study was to assess the likely impact of the US Food and Drug Administration (FDA) advisory not to use over-the-counter (OTC) cough and cold products for children aged <2 years on care provided by pediatricians and parents.

METHODS

A mailed survey was completed by 105 community pediatricians (53% response rate), and 1265 parents with children aged <12 years completed a self-administered survey while waiting for an office visit.

RESULTS

All physicians were aware of the advisory; 75% agreed with it. Fifty-nine percent did not recommend OTC cough and cold products for children aged <2 years before the advisory, and 35% were less likely to do so afterward. Seventy-three percent of parents were aware of the advisory, 70% believed these products relieved symptoms, 68% did not believe they were dangerous, and 74% had them at home. After the advisory, 21% of parents were more likely to request an antibiotic from the doctor. Among the parents, 225 only had children aged <2 years and 695 only had children aged 2 to 11 years; of these parental groups, 53% and 10% of parents, respectively, did not use these products before the advisory, an additional 33% and 28%, respectively, were less likely to do so afterward, and 15% and 61%, respectively, would continue use them.

CONCLUSIONS

Pediatricians must be prepared for requests from parents for antibiotics and other remedies for symptom relief for their children with colds. As no effective alternatives are available, maybe nontreatment should be promoted.

Infant Botulism and Raised Intraocular Pressure

Infant botulism is an exceedingly rare disease. Because confirmatory laboratory testing is not available for several days after time of presentation, infant botulism remains a clinical diagnosis. The authors demonstrate how raised intraocular pressure may provide an additional clinical clue to making the diagnosis.

From poison to remedy: the chequered history of botulinum toxin

Botulinum toxin poisoning has afflicted mankind through the mists of time. However, the first incident of food-borne botulism was documented as late as the 18th century, when the consumption of meat and blood sausages gave rise to many deaths throughout the kingdom of Württemberg in South Western Germany. The district medical officer Justinus Kerner (1786--1862), who was also a well-known German poet, published the first accurate and complete descriptions of the symptoms of food-borne botulism between 1817 and 1822 and attributed the intoxication to a biological poison. Kerner also postulated that the toxin might be used for treatment purposes. In 1895, an outbreak of botulism in the small Belgian village of Ellezelles led to the discovery of the pathogen "Clostridium botulinum" by Emile Pierre van Ermengem. Modern botulinum toxin treatment was pioneered by Alan B. Scott and Edward J. Schantz in the early 1970s, when the type-A serotype was used in medicine to correct strabismus. Other preparations of the type-A toxin were developed and manufactured in the United Kingdom, Germany, and China, whereas a therapeutic type-B toxin was prepared in the United States. To date, the toxin has been used to treat a wide variety of conditions associated with muscular hyperactivity, glandular hypersecretions and pain.

Laboratory diagnostics of botulism

Botulism is a potentially lethal paralytic disease caused by botulinum neurotoxin. Human pathogenic neurotoxins of types A, B, E, and F are produced by a diverse group of anaerobic spore-forming bacteria, including Clostridium botulinum groups I and II, Clostridium butyricum, and Clostridium baratii. The routine laboratory diagnostics of botulism is based on the detection of botulinum neurotoxin in the patient. Detection of toxin-producing clostridia in the patient and/or the vehicle confirms the diagnosis. The neurotoxin detection is based on the mouse lethality assay. Sensitive and rapid in vitro assays have been developed, but they have not yet been appropriately validated on clinical and food matrices. Culture methods for C. botulinum are poorly developed, and efficient isolation and identification tools are lacking. Molecular techniques targeted to the neurotoxin genes are ideal for the detection and identification of C. botulinum, but they do not detect biologically active neurotoxin and should not be used alone. Apart from rapid diagnosis, the laboratory diagnostics of botulism should aim at increasing our understanding of the epidemiology and prevention of the disease. Therefore, the toxin-producing organisms should be routinely isolated from the patient and the vehicle. The physiological group and genetic traits of the isolates should be determined.

Human botulism immune globulin for the treatment of infant botulism

BACKGROUND

We created the orphan drug Human Botulism Immune Globulin Intravenous (Human) (BIG-IV), which neutralizes botulinum toxin, and evaluated its safety and efficacy in treating infant botulism, the intestinal-toxemia form of human botulism.

METHODS

We performed a five-year, randomized, double-blind, placebo-controlled trial statewide, in California, of BIG-IV in 122 infants with suspected (and subsequently laboratory-confirmed) infant botulism (75 caused by type A Clostridium botulinum toxin, and 47 by type B toxin); treatment was given within three days after hospital admission. We subsequently performed a 6-year nationwide, open-label study of 382 laboratory-confirmed cases of infant botulism treated within 18 days after hospital admission.

RESULTS

As compared with the control group in the randomized trial, infants treated with BIG-IV had a reduction in the mean length of the hospital stay, the primary efficacy outcome measure, from 5.7 weeks to 2.6 weeks (P<0.001). BIG-IV treatment also reduced the mean duration of intensive care by 3.2 weeks (P<0.001), the mean duration of mechanical ventilation by 2.6 weeks (P=0.01), the mean duration of tube or intravenous feeding by 6.4 weeks (P<0.001), and the mean hospital charges per patient by 88,600 dollars (in 2004 U.S. dollars; P<0.001). There were no serious adverse events attributable to BIG-IV. In the open-label study, infants treated with BIG-IV within seven days of admission had a mean length of hospital stay of 2.2 weeks, and early treatment with BIG-IV shortened the mean length of stay significantly more than did later treatment.

CONCLUSIONS

Prompt treatment of infant botulism type A or type B with BIG-IV was safe and effective in shortening the length and cost of the hospital stay and the severity of illness.

Catastrophic presentation of infant botulism may obscure or delay diagnosis

Three infants with infant botulism are presented to illustrate how atypical, early, and severe features may obscure or delay diagnosis. Two boys aged 6 weeks and 20 days, respectively, presented with rapid deterioration after brief periods of poor feeding, one with an apparent life-threatening event at home and the other with a full cardiopulmonary arrest. Initial abnormal laboratory findings of coagulopathy suggested sepsis in the first infant. In the second infant, severe acidosis and hypoglycemia suggested an underlying metabolic disorder. A third infant, aged 1 month, was hospitalized originally with an admitting diagnosis of "pharyngitis" resulting from his inability to take adequate feedings. He received intravenous fluids and antibiotics. One week later he suffered a respiratory arrest. Laboratory findings of severe hyponatremia and acidosis at the time of his arrest suggested a metabolic etiology. Even retrospectively, none of these infants had the typical initial complaint of constipation, and none were noted to have ptosis or facial weakness before catastrophic collapse. However, in each case, the parent had initially brought the child to the physician for "poor feeding" or "poor suck," which was not recognized by medical personnel as a result of bulbar weakness. Ultimately, all 3 infants were found to have infant botulism. All 3 had received antibiotics before catastrophic collapse, possibly contributing to the rapidity of the deterioration. Each recovered, although the delay in diagnosis made them ineligible for treatment with botulism immunoglobulin.

Association between honey consumption and infant botulism

Infant botulism, a disease that results in a blockade of voluntary motor and autonomic functions, was first recognized in the United States in the late 1970s. Since then, more than 1000 cases in this country have been reported to the Centers for Disease Control and Prevention (CDC). Numerous studies have shown that the ingestion of honey is linked with infant botulism. In addition, honey samples across the United States have tested positive for Clostridium botulinum spores and toxins. Such substantial evidence led the CDC to recommend that honey not be given to infants younger than 12 months old. It is important that clinicians be familiar with this risk and should not recommend honey-containing products or supplements or the use of honey as a flavoring agent for infants in this age group.

Clostridium botulinum and the ophthalmologist: a review of botulism, including biological warfare ramifications of botulinum toxin

The anaerobic bacterium Clostridium botulinum causes disease by elaborating an extremely potent neurotoxin that inhibits release of acetylcholine at presynaptic nerve endings, thereby resulting in a descending flaccid paralysis and autonomic nervous system dysfunction. Possible ophthalmological effects of this neurotoxin are many and typically constitute the earliest manifestations of botulism. This review summarizes the medical literature on botulism with regard to historical perspective, epidemiology, clinical manifestations, and treatment. Ophthalmological findings of botulism are tabulated and their frequencies are provided. Finally, the bioterrorism/biologic warfare ramifications of botulinum toxin are briefly discussed.

Clostridium botulinum and bio-compost. A contribution to the analysis of potential health hazards caused by bio-waste recycling

Bio-waste recycling and the production and use of bio-compost are politically encouraged in Europe. Quality control takes no consideration of pathogenic anaerobic spore formers, e.g. Clostridium botulinum. A protocol for health hazard analysis concerning this pathogen has been developed. Samples of marketed bio-compost were tested and results showed that about 50% of the tested samples contained C. botulinum. For the first time it has been shown that the use of bio-compost represents a health hazard to humans and animals, especially in the future when spores will have accumulated in the environment. The use of household bio-waste collected in 'bio-bins' is apparently one factor involved in the production of contaminated compost end-products. Environmental factors in the propagation of C. botulinum are discussed. The improvement of bio-waste recycling technology and management should be encouraged in order to minimize the health hazard caused by contaminated bio-compost.

Host damage from bacterial toxins

Bacterial infection often involves toxin-mediated damage to the host. This can occur at mucosal epithelial surfaces, in subepithelial tissues (involving connective tissue, blood vessels and host defence cells), or at organ or tissue sites distant from the focus of infection. This paper deals with host damage at each of these levels and examples have been selected of toxins that have a well defined role in pathogenesis and for which evidence is less clear cut. Current views of mechanisms of host damage are presented along with summaries of mode of action at the molecular level where this is known. Certain unifying features of mechanisms of toxin action on host cells are emphasised. Modern genetic methods and gene cloning techniques should help in the assessment of the role of individual toxic factors where pathogenesis is multifactorial, and preliminary examples of this approach are mentioned. The search for new toxins continues and this is illustrated with reference to the toxins involved in the staphylococcal scalded skin syndrome and staphylococcal toxic shock syndrome. This overview is intended to convey an impression of the rapid development that has taken place in knowledge of the role of toxins in pathogenesis.

Disorders of neuromuscular transmission due to natural environmental toxins

A variety of natural toxins of animal, plant, and bacterial origin are capable of causing disorders of neuromuscular transmission. Animal toxins include venomous snakes and arthropods, venoms of certain marine creatures, skin secretions of dart-poison frogs, and poisonous fish, shellfish, and crabs. There are plant poisons such as curare, and bacterial poisons such as botulinum toxin. These act at single or multiple sites of the neuromuscular apparatus interfering with voltage-gated ion channels, acetylcholine release, depolarization of the postsynaptic membrane, or generation and spread of the muscle action potential. The specific actions of these toxins are being widely exploited in the study of neuromuscular physiology and pathology. Some toxins have proved to be valuable pharmaceutical agents. Poisoning by natural neurotoxins is an important public health hazard in many parts of the world, particularly in the tropics. Poisoning may occur by a bite or a sting of a venomous animal, or by the ingestion of poisonous fish, shellfish or other marine delicacies. Contaminated food is a vehicle for poisons such as botulinum toxin. Clinically, a cardinal feature in the symptomatology is muscle paralysis with a distribution characteristic of myasthenia gravis, affecting muscles innervated by cranial nerves, neck flexors, proximal limb muscles, and respiratory muscles. Respiratory paralysis may end fatally. This paper reviews from the clinical and pathophysiologic viewpoints, naturally occurring environmental neurotoxins acting at the neuromuscular junction.

Effect of 3,4-diaminopyridine on the survival of mice injected with botulinum neurotoxin type A, B, E, or F

To determine the efficacy of 3,4-diaminopyridine (3,4-DAP) as a potential treatment for botulism, its effect on the survival times of mice injected with type A, B, E, or F botulinum toxin (Bo Tx) was examined. Mice were injected ip with 10, 20, or 40 LD50 of Bo Tx. Three hours later, when the mice displayed signs of botulism, half of each group of mice was treated with 3,4-DAP, an agent which increases nerve-evoked transmitter release. At each dose of type A Bo Tx tested, 3,4-DAP definitely prolonged survival. In contrast, treatment with the drug did not significantly increase the survival time of mice injected with type B, E, or F Bo Tx. The differences in efficacy of 3,4-DAP against the four serotypes of Bo Tx together with previously reported variations in specific toxicity and duration of paralysis may reflect differences in the pharmacological activity of these neurotoxins.

[Value of bacteriologic studies within the scope of forensic autopsies]

The various questions regarding bacteriological investigations within the scope of forensic autopsies are discussed in the light of our own cases and with regard to the relevant literature: estimate of the age of the corpse on the basis of decomposition changes caused by bacteria; determination of so-called bacteriograms from the point of view of criminalistics; supplementary investigations of the cause of death. Iatrogenic infections (e.g., gangrene) are gone into in more detail, as is so-called infantile botulism within the scope of the "sudden infant death syndrome". Finally, it is pointed out that when doing forensic autopsies, thought should also be given to illnesses that have only been known for a few years, examples being legionnaires' disease and the toxic shock syndrome ("tampon sickness").

Infant botulism in the United States: an epidemiologic study of cases occurring outside of California

Data were obtained for the 96 hospitalized cases of infant botulism reported to the Centers for Disease Control between 1976-1980 from all states other than California. Forty-one cases were associated with Clostridium botulinum type A, 53 with type B, one with type F, and one with a strain of C. botulinum capable of producing both type B and F toxin. Cases occurred in 25 states; the disease was more common in the western part of the United States, with the highest attack rates reported for Utah and New Mexico. Birth-weights of hospitalized infants with infant botulism tended to be high compared with birth-weights in the United States population. Mothers of infants with infant botulism tended to be older and better educated than mothers in the general population. Seventy per cent of infants had been predominantly breast-fed; breast-feeding in type B cases was associated with a significantly older age at onset of illness.

Serum antibody response to Clostridium botulinum toxin in infant botulism

A serum antibody response has not been previously demonstrated after infection with Clostridium botulinum. We developed an enzyme immunoassay for measuring serum antibody to C. botulinum toxins A, B, and E. This assay system detected a specific immunoglobulin G and immunoglobulin M antibody response to C. botulinum toxin in two patients with infant botulism.

The rat as an animal model for infant botulism

Susceptibility to intraintestinal Clostridium botulinum colonization of conventional infant and germfree adult rats is comparable to that of mice. C. botulinum-monoassociated rats pass C. botulinum toxin in their milk.

Isolation of Clostridium botulinum from Honey

Methods for the isolation of Clostridium botulinum from honey samples are described. A total of 9 of 90 honey samples were positive for C. botulinum; 6 of the positive samples had been fed to babies who developed infant botulism.

Intestinal infection and toxin production by Clostridium botulinum as one cause of sudden infant death syndrome

The spontaneous production of botulinum toxin in the infant gut by ingested Clostridium botulinum organisms is the underlying cause of infant botulism, recognised as an infectious disease only in late 1976. Because of the recognition of the pathophysiology of this disease and because the known potency and action of botulinum toxin can lead to rapid respiratory arrest, it appeared possible that the in-vivo production of botulinum toxin could cause the sudden death of some infants. To test this hypothesis, serum, selected tissues, and bowel contents from 280 dead infants were examined for the presence of C. botulinum toxin and/or organsisms. We found C. botulinum organisms in 10 infants, all of whom died suddenly and unexpectedly. 9 of these deaths were classified by the forensic pathologist as sudden infant death syndrome (S.I.D.S. or crib death). In 2 of these 10 sudden deaths both C. botulinum organisms and botulinum toxin were identified, and from the spleen of 1, C. botulinum organisms were isolated. Faecal specimens from 160 age-matched healthy infants who served as controls in studies of inpatient infant botulism cases were negative for both C. botulinum organisms and toxin, except for one specimen that contained only C. botulinum type A organisms. The 9 S.I.D.S. cases with evidence of C. botulinum infection comprised 4.3% of the 211 S.I.D.S. cases examined over 12 months. These findings suggest that intestinal production of botulinum toxin by C. botulinum is one cause of S.I.D.S. The strikingly similar age-distribution of 62 inpatient infant botulism cases and the 211 S.I.D.S. cases is also consistent with this concept. The possibility that in-vivo production of botulinum toxin may account for a larger proportion of S.I.D.S. cases is discussed.

Infant botulism in England

A 24-week-old girl presented with an acute illness characterised by constipation at 22 weeks, followed a week later by the sudden onset of generalised weakness, poor feeding, and a weak cry. Laboratory examination of her stools confirmed the clinical diagnosis of infant botulism.