A case of a four month old boy with botulism is reported from the Department of Microbiology, Bristol Royal Infirmary and Bristol Royal Hospital for Sick Children, England. For the week before admission he had profuse rhinorrhea, and for 24 hours there was difficulty in feeding, hypotonia, and respiratory distress. On admission, he was profoundly hypotonic and had bilateral ptosis, impassive facies, depressed deep tendon reflexes and gag reflex, and pharyngeal pooling of saliva. He was mentally alert and responded to painful stimuli. Intravenous edrophonium (0.1 mg/kg) had no effect. EMG showed reduced amplitude of motor action potentials. EEG showed generalized high amplitude slow wave activity. Intermittent positive pressure ventilation was required and he began to show improvement by day 18 and was extubated on day 24. Clostridium botulinum and its toxin were isolated from the feces. [1]

COMMENT. Infantile botulism is rare, this being only the second case in the United Kingdom. The diagnosis should be entertained in infants with an acute onset of hypotonia and respiratory distress. Honey has been implicated in several cases from the United States [2]. Fortunately, almost all infants recover completely, the illness lasting between 3 and 20 weeks, but supportive therapy is necessary and the differentiation from neonatal myasthenia gravis, septicemia, and infectious polyneuritis is important.

Botulinum toxin is not all bad! Local intradermal injections of botulinum A toxin may be useful in the treatment of eyelid and facial spasms in patients with generalized dystonias according to a report from the University of California School of Medicine, San Francisco [3]. Very small doses of botulinum A toxin are required but the effect is limited to a few months.