The parents of a previously healthy 4-month-old infant, Grace, were alarmed when she suddenly became extremely cranky and her cry sounded weaker than usual. That night while breastfeeding the baby had a weak latch. Her parents were concerned with her stark change in behavior and decided they would bring her to her pediatrician the next day if she skipped another feeding. The following morning, Grace’s condition had worsened. Her cry was even weaker, she was unable to feed, and her parents noted she had the appearance of a “floppy rag doll.” When the parents called her name, Grace did not respond, and her mother described Grace as “looking right through me.” The parents called 911 because they believed Grace was having a seizure. The baby was brought to the hospital by emergency services. Once in the trauma bay, Grace went into respiratory arrest twice. After she was stabilized, she was admitted to the pediatric intensive care unit for further workup and observation.

On physical examination, Grace exhibited hypotonia with loss of deep tendon reflexes in the upper extremities and later progressing to the lower extremities. In addition, Grace’s examination displayed ptosis, impairment in extraocular movements, a mottled skin appearance, and drooling that required frequent suctioning. All other portions of the physical examination were normal, including her vital signs. Her history was positive for constipation, but otherwise she had been completely healthy and had been delivered vaginally at 38 weeks without complications.

Cerebrospinal fluid analysis ruled out meningitis. Blood cultures, complete blood count, and comprehensive metabolic panel were all within normal limits. Electroencephalography was performed and ruled out seizure. Computed tomographic examination of the head was negative for any signs of trauma. Urinalysis showed increased white cells. Based on these findings, the working diagnosis was either a urinary tract infection or a metabolic disease. However, the medical team was stumped by Grace’s continuing physical deterioration. They could not determine an obvious cause of her hypotonia (referred to as “floppy baby syndrome”).

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Grace’s mother noticed that her baby attempted to feed but could not swallow and asked the clinician to further examine the pharynx. Upon examination there was noted to be loss of the patient’s gag and swallow reflex. Although having had no personal experience with such a case, the clinician believed that Grace might be demonstrating signs of infant botulism. Electrophysiology studies were performed and exhibited findings characteristic of infant botulism. A stool sample was collected and sent for confirmation.

After the clinical diagnosis of infant botulism was made, botulinum immune globulin (BabyBIG®) was ordered from the Centers for Disease Control and Prevention (CDC) and flown in from California where it is produced. Once it arrived, the medication was infused intravenously for 1 hour.

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BabyBIG immune globulin was curative for Grace. Fortunately, during the course of her two-week hospital stay she did not require intubation despite her serious symptoms. Occupational therapy, physical therapy, and speech therapy were consulted. Following appropriate treatment, Grace made a full recovery and is now a healthy toddler who has reached all of her milestones.