Ruth Koepke , Jeremy Sobel and Stephen S . Arnon Global Occurrence of Infant Botulism

OBJECTIVE. To summarize the worldwide occurrence of reported infant (intestinal toxemia) botulism cases since first recognition of the disease in 1976. PATIENTS AND METHODS.We collected information on infant botulism cases by active and passive surveillance, by provision of therapeutic Human Botulism Immune Globulin to suspected cases, and by searching the medical literature. We defined a case as laboratory-confirmed botulism that occurred in an infant 12 months of age that was not caused by the ingestion of botulinum toxin in food. RESULTS. Twenty-six countries representing 5 continents reported the occurrence of at least 1 case of infant botulism among their residents. The United States, Argentina, Australia, Canada, Italy, and Japan, in this order, reported the largest number of cases. A history of honey exposure was significantly more common among case subjects hospitalized outside of the United States than among those who were recently hospitalized in California. CONCLUSIONS.Most countries have not yet reported cases of infant botulism. This limited reporting of the disease to date contrasts with the known global occurrence of Clostridium botulinum spores in soils and dust and suggests that infant botulism may be underrecognized, underreported, or both. When bulbar palsies, hypotonia, and weakness are present, physicians should consider the possibility of infant botulism even if the patient has not been fed honey. Publication of additional case reports and surveillance summaries will enhance understanding of the occurrence and extent of this underrecognized disease. Pediatrics 2008;122:e73–e82 I BOTULISM IS an uncommon disease that occurs when ingested spores of the common soil-dwelling bacterium Clostridium botulinum (or, rarely, toxigenic Clostridium butyricum or Clostridium baratii) germinate and produce botulinum neurotoxin in the colon. The resulting illness varies in severity from outpatient mild hypotonia to hospitalized systemic flaccid paralysis to sudden unexpected death.1–4 The broad spectrum of severity and nonspecific presentation may make infant botulism difficult to diagnose and result in its being underrecognized and underreported.2 To assess the global occurrence of infant botulism, we identified countries that have reported infant botulism cases, summarized the cases reported, and compared selected epidemiological and clinical features of cases identified outside of the United States with those identified inside the United States.