Two Cases of Infant Botulism Presenting with Altered Mental Status

Area of Science:

• Neurology
• Pediatrics
• Infectious Diseases

Background:

• Infant botulism, caused by *Clostridium botulinum* toxin, typically presents with descending weakness, facial palsies, and constipation.
• While *Clostridium botulinum* is widespread in the US, infant botulism is infrequently reported in Hawai'i.

Observation:

• This report details two infant botulism cases in Hawai'i with unusual initial symptoms: altered mental status (Patient A) and somnolence with fever post-immunization (Patient B).
• Patient A initially presented with inconsolability and progressed to loss of gag reflex and constipation, initially suspected as meningitis.
• Patient B exhibited somnolence and fever after immunizations, leading to consideration of metabolic disorders before botulism diagnosis.

Findings:

• Both patients were eventually diagnosed with infant botulism (toxin B for Patient A, toxin A for Patient B) despite atypical initial presentations.
• Altered mental status and fever are not typical early signs of infant botulism, highlighting diagnostic challenges.

Implications:

• Infant botulism should be considered in infants presenting with altered mental status, especially when accompanied by constipation and weakness, even if initial evaluations suggest other causes.
• Prompt consideration of infant botulism in infants with altered mental status and developing neuromuscular weakness is vital for timely diagnosis and treatment.
• Contacting the Infant Botulism Treatment and Prevention Program early is recommended for diagnostic and therapeutic assistance.