SUMMARY A 4 month old boy presented with respiratory difficulty and hypotonia. Clostridium botulinum and its toxin were isolated from his faeces and he had electromyographic changes typical of infantile botulism. This is only the second case in the United Kingdom: unfamiliarity with the presentation could result in misdiagnosis.Infantile botulism results from the production of Clostridium botulinum toxin in the infant gut. It was first recognised in 19761 and more than 600 cases have been reported since, most of them from North America. Only one previous case has been reported in the United Kingdom, which was caused by C botulinum type A.2 We describe a second case, and only the third ever reported caused by C botulinum producing toxins B and F.
Case reportThe patient was a boy aged 4 months. He was born at full term after a normal pregnancy, was breast fed from birth, and growth and development were normal. He was given his first doses of diphtheria, tetanus, pertussis, and oral poliomyelitis vaccines three weeks before admission to hospital. Baby rice and rusks were added to his diet about one week later because of 'constipation' attributed by his parents to underfeeding, and for the week before admission he had had profuse rhinorrhoea.Twenty four hours before admission he had difficulty feeding, and was less active than normal. By the next day he was 'floppy' and in respiratory distress, and on admission there was profound generalised hypotonia with bilateral ptosis, impassive facies, reduced tendon reflexes, a poor gag reflex, and pharyngeal pooling. Spontaneous movements were few but he seemed visually alert and showed definite withdrawal from pain. Physical examination otherwise yielded normal results.Haematological measurements were unremarkable, and normal biochemical results included blood urea, electrolytes, creatinine, glucose, and lead concentrations, and normal aspartate transaminase activity. Urinary An electroencephalogram on admission showed generalised excess high amplitude slow wave activity. This non-specific abnormality was rather more pronounced a week later, but thereafter returned to normal.The patient was initially treated with netilmicin and ampicillin; subsequent management was supportive. Two days after admission (day four of the illness) intermittent positive pressure ventilation was required. Although he retained some respiratory movements throughout his illness he showed profound hypotonia, losing pupillary reflexes for several days.The child began to show definite improvement by day 18 and was extubated on day 24. Improvement was then rapid, his air of alertness progressing in advance of his muscular strength. He was discharged on day 45, able to feed from a bottle. He still had considerable hypotonia but was responsive, babbled, and was able to grasp toys. This improvement has continued.Faecal specimens were sent to