Since February 1976, 4 California infants, all 3 months of age or less, have been found to have botulism. In February a previously well, 5-week-old infant developed constipation, irritability, and weakness, first manifested by diminished crying and sucking. Over the next several days the baby lost neck and limb strength and became "floppy." Neurological impairment included ptosis, sluggish pupillary light reaction, facial weakness, flaccid neck and limb muscles, and poor anal sphincter tone. Stool from this infant collected at this time was later shown to contain type A botulinal toxin and Clostridium botulinum organisms; his serum was negative for toxin. Treatment was primarily supportive. Antibiotics were administered but antitoxin was not. The infant recovered completely and on follow-up had no neurological deficits. Botulinal toxin and organisms continued to be present in stool specimens for 8 weeks after complete clinical recovery. After establishment of the diagnosis in the first case, another infant in Northern California and 2 infants in Southern California with similar clinical illnesses were identified. One of these infants had a respiratory arrest before being hospitalized. Stool specimens from these 3 infants contained toxin (2 type B and 1 type A) and C. botulinum organisms. Serum specimens were negative for toxin. These 3 other infants with botulism were treated with supportive care and antibiotics but with no botulinal antitoxin. All have recovered without sequelae. An extensive investigation for the possible source of ingested toxin in each of the 4 cases has been unrevealing. In each instance, the infant was the only ill family member. Two infants were primarily breast-fed and 2 were formulafed; however, all 4 infants had some exposure to other food. To date, no toxin has been found in samples of food or drugs that had been fed to the infants. C. botulinum organisims were isolated from honey that 1 infant had eaten. It is unlikely that these infants were exposed to food with preformed toxin. Furthermore, an occult common source exposure does not appear to be responsible for these cases, since 2 were type A and 2 were type B. Reported in California Morbidity No. 21, June 4, 1976, and No. 34 (Suppl), Sept 3, 1976. Editorial Note: The California infants, along with a 22month-old New Jersey infant with confirmed type B botulism reported in 1975 (MMWR 25[9], represent a new recognition of botulism in this age group. Identifying 5 cases in the last 18 months suggests that botulism in infants may be more common than previously recognized. Physicians should consider botulism in infants with unexplained weakness, ophthalmoplegia, dysphagia, or respiratory arrest. The presence of toxin in stool and not in serum in these 4 cases illustrates the importance of testing both types of specimens from each infant with suspected botulism. One hypothesis of the pathogenesis of botulism in these infants is that in vivo germination of ingested C. botulinum spores resulted in the production of toxin in the infants' intestines. There is experimental evidence to support this concept (1,2). C. botulinum spores are found in soil and dust; therefore, they may be found on raw foods. Since the spores are heat-resistant, even well-cooked food may also contain viable C. botulinum spores. There are thus several potential environmental sources of C. botulinum organisms for susceptible infants. The mechanism of recovery from the illness remains obscure, particularly since toxin and organisms have been found in stool for at least 8 weeks after clinical recovery. Antibodies to botulinum toxin have not been measured to determine if humoral immunity may contribute to recovery. C. botulinum organisms may ultimately be eliminated by competition produced by other bacterial flora. References 1 Orr PF: The pathogenicity of Bacillus botulinus. J Infect Dis 30:118-127,1922 2. Coleman GE, Meyer KF: Pathogenicity of B. botulinus. J Infect Dis 31:622-649, 1922 U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE / PUBLIC HEALTH SERVICE As of August 31, 1976, there were 179 cases of respiratory illness including 28 deaths that could be related to attendance at the American Legion convention in Philadelphia or to the headquarters hotel with onsets between July 1 and August 18, 1976 (Figure 1).* Affected were 148 conventioneers and 31 non-conventioneers. Cases ranged in age from 3 to 83 years, mean age 55.6 years; 140 were males; 68 were known to have significant preexisting illness, such as cardiopulmonary disease, diabetes mellitis, and malignancy. The case-fatality ratio was 29% for those with preexisting illness and 5% for those without. Seven cases including 2 who died were persons who had attended the Eucharistic Congress in Philadelphia on August 1-8. Preliminary autopsy findings for a 62-year-old man who became ill on August 11 suggested bacterial pneumonia. The other case who died was a 71-year-old woman who became ill on August 12 and died on August 25. Autopsy materials from A case is defined as illness occurring between July 1 and August 18, 1976, characterized by either fever and chest X-ray evidence of pneumonia, or temperature of 102°F or higher and cough (clinical criteria) in a person who either attended the American Legion convention in Philadelphia or had been in the headquarters hotel after July 1, 1976. Persons who meet the case criteria are hereafter referred to as "cases." *Total 179 cases, date of onset unknown for 2 Preliminary evidence indicates that neither food nor Table I. Summary-Cases of Specified Notifiable Diseases: United States *Delayed reports: Asep. Meng: Wisc, add 1; Chickenpox: Calif. add 3; Enceph.: Wisc. add 1; Hep. B: Mo. delete 1, W. Va. add 1; Hep. A: Mo. delete 1, La. delete 2, Nev. and 1; Hep. unsp. Mo. delete I. *Delayed reports: Measles: Pa add 6, Mo. add 1, Wash, delete 3; Men. Inf.: Mo. delete 2; Mumps: Vt. delete 2, Mo. add 1; Pertussis: Mo. add 1. Guam Puerto Rico Virgin Islands 151 Table III-Continued Cases of Specified Notifiable Diseases: United States TYPHUS-FEVER 273 TICK-BORNE (RMSF) REPORTING AREA *Delayed reports: TB: Mich. delete 2, Mo. delete 1, Va. delete 12, N. Car. delete 7, Ky, delete 2, Alaska delete 1; Typhoid fever: W. Va. add 1; RMSF: Mo. add 1, N. Car, delete 1, Okla. delete 4, Wash, delete 1; GC: La. delete 25, Nev. add 8, V.I. add 2; Syphilis: N. Hamp. delete 1, Vt. add 2, La. delete 6, V.I. add 1. |