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354 Case of infant botulism and review of the use of heptavalent botulinum antitoxin for treatment
  1. Karen Donceras Nadua,
  2. Ann Chuan En Loh,
  3. Terrence Gerard Sundram Thomas,
  4. Matthias Maiwald,
  5. Xue Fen Valerie Seah,
  6. Natalie Woon Hui Tan
  1. Singapore


Background Infant botulism is a rare and potentially lethal condition resulting in symmetrical descending flaccid paralysis, caused by ingestion of Clostridium botulinum spores. Human Botulism Immune Globulin Intravenous (BIG-IV) is deemed safe and effective in reducing inpatient and intensive care unit (ICU) stay for infants with botulism. However, the high cost of BIG-IV and the time to procurement from the United States can be prohibitive. A possible alternative is the heptavalent botulinum antitoxin (HBAT), an equine-derived antitoxin licensed for use for treatment of non-infant botulism.

Objectives To present a case of infant botulism and review the use and safety of heptavalent botulinum antitoxin as treatment for infant botulism.

Methods Case report and review of literature.

Results A three-month-old female infant weighing 5.3 kg presented to our hospital with two days of reduced feeding, poor suck and lethargy. She subsequently developed acute flaccid paralysis with bulbar involvement. History revealed ingestion of 1 milliliter of raw honey about 3 weeks prior to symptom onset. She was transferred to the ICU for non-invasive respiratory support on and also required nasogastric tube feeding. Her stool botulism neurotoxin gene PCR was positive for type A and B genes. A nerve conduction study demonstrated a pre-synaptic neuromuscular junction defect consistent with the diagnosis of infant botulism.

A collaborative decision between parents and clinicians was made for HBAT over BIG-IV due to lower cost and availability in Singapore. On day 6 of admission, she was given HBAT (10% of vial, 1.6 mL once) using a slow incremental infusion rate, with close monitoring of vital signs and with diphenhydramine as premedication. She did not experience any adverse effects. Her condition improved and she was eventually discharged after 18 days of hospitalization.

Only few studies describe the use of HBAT in infant botulism and the experience in children is limited, especially in infants. This adds to the limited data available for the use of HBAT in infants, and suggests that HBAT may be safe and effective for use in infant botulism.

Conclusions Infant botulism is a rare condition that requires prompt diagnosis and treatment. In a setting where the BIG-IV is not accessible in a timely manner due to high cost or logistics, HBAT can be considered as a safe and effective alternative for the management of infant botulism.

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