In patients with wound botulism, the wound should be débrided. Antibiotics should be given for coexisting infection, but no studies have shown that their administration hastens recovery from the paralysis.

For infantile botulism, supportive care is, again, the backbone of treatment. Antibiotics are ineffective.⁵ The antitoxin is not used in infants out of concern about reactions to the horse serum derivative.

Recently, human botulism immune globulin (HBIG) has been made available by the FDA for infantile botulism only. Like the antitoxin, it has been shown to decrease ICU length of stay, ventilation requirements, and mortality.⁹ It can be obtained by calling the Infant Botulism Treatment and Prevention Program at 510-231-7600.

Case Resolution

The infant who was not feeding normally was recognized to have an at-risk airway and ventilatory status and was immediately intubated. A sepsis workup was initiated, including a CBC, urinalysis, blood and urine cultures, a chest radiograph, and a lumbar puncture. Results of a thorough ophthalmoscopic examination and a noncontrast computed tomography scan of the head were normal. The child was empirically started on vancomycin, ceftriaxone, and acyclovir and admitted to the pediatric ICU for further management.

One day after admission, all cultures were negative, and infantile botulism was considered. Minimal stool was obtained and sent to the state laboratory, where it was found to be positive for botulinus toxin. Her providers called the Infant Botulism Treatment and Prevention Program and obtained HBIG, which was administered at a dose of 50 mg/kg. She had a prolonged period of mechanical ventilation but was eventually discharged home with no residual morbidity.

Summary

Emergency physicians have the difficult job of rapidly evaluating and managing disease that may be presenting quite early in its evolution. Through diligence and attention to detail, emergency physicians should be able to identify botulism. Once this disease is suspected, the initial management is directed toward ensuring that the airway is protected and that the patient does not require immediate or urgent ventilatory assistance. Once this lifesaving intervention has been considered or implemented, emergency physicians should further evaluate these patients and involve the appropriate consultants to admit the patient to the hospital. It is important to remember that laboratory testing from the emergency department is unlikely to confirm this disease process, although it could help rule out other etiologies for the patient’s symptoms.

Pearls

• Consider the diagnosis of botulism in toxic-appearing infants.
• All patients with suspected botulism should be admitted to the ICU.
• Findings that suggest the diagnosis of botulism are dry mouth, double vision, difficulty speaking, dysphagia, diplopia, and fixed and dilated pupils.
• Contact the CDC or local health department to obtain HBIG or botulism antitoxin as soon as the diagnosis is suspected.
• Pitfalls
• Not identifying subtle weakness by conducting a squat down or heel raise test.
• Failing to initiate rapid airway control and respiratory support in a patient who is deteriorating secondary to presumed botulism.

Questionnaire Is Available Online

This educational activity is designed for emergency physicians and should take approximately 1 hour to complete. Participants will need an Internet connection through Firefox, Safari or Internet Explorer 6.0 or above to complete this Web-based activity. The CME test and the evaluation form are located online at www.ACEP.org/focuson.