More Than Just a Floppy Baby: Maintaining High Clinical Suspicion of Infant Botulism

Infant botulism is a rare and life-threatening condition if left untreated. We report the case of a previously healthy four-week-old male in Arkansas, who presented with progressive lethargy, feeding difficulties, and respiratory compromise following a recent viral respiratory illness. His clinical course was notable for worsening hypotonia, absent reflexes, and eventual respiratory failure requiring intubation. Extensive evaluation for infectious, neurologic, and metabolic causes was initially unrevealing, but further exposure history revealed constipation paired with recent soil exposure, raising suspicion for infant botulism. Botulinum immune globulin (BabyBIG®) was administered, with subsequent gradual clinical improvement. Stool testing later confirmed the presence of botulinum toxin type B. The patient was discharged in stable condition, tolerating full oral feeds, and without further complications. This case underscores the diagnostic difficulty of infant botulism due to early age at presentation, anchoring bias with diagnosis of a recent viral illness, and overlapping symptoms with other neonatal conditions. A detailed exposure history is critical, and early clinical suspicion can facilitate timely treatment and improve outcomes.