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Table 1.  

Patient no. Age, mo/sex Ethnicity Term or preterm Birthweight, kg No. siblings Region Location type Form of housing
1 2.5/F Bedouin Term 3.1 3 Negev (South) Rural Temporary shed
2 4/M Jewish Term 3.1 3 Negev (South) Urban Apartment building
3 6/M Jewish Term 3.3 1 Center Urban Apartment building
4 8/F Jewish Late preterm 1.9 1 Center Rural Private house
5 7/M Jewish Term 3.2 1 Center Urban Private house
6 8/M Jewish Term 2.9 0 Galil (North) Urban Apartment building
7 5/F Jewish Term 2.8 1 Center Urban Apartment building
8 7/M Jewish Term 3.6 4 Center Urban Apartment building

Table 1. Demographic and clinical characteristics of infant botulism patients, Israel, 2007–2021

Table 2.  

Category Value
Clinical feature, no. positive/no. tested

Respiratory distress

3/8

Ptosis

6/8

Facialis

1/8

Poor feeding

7/8

Descending paralysis

6/8

Depressed tendon reflexes

4/6

Hypotonia

8/8

Constipation

7/8

Hoarseness

3/8

Aspiration or decreased gag reflex

4/8

Weak cry

7/8

Lack of smile

4/8

Drooling

1/8

Mydriasis

2/8
Diagnostic tool used, no. positive/no. tested

Electromyographic test

3/4

Toxin A

3/8

Toxin B

5/8

Stool PCR

2/2

EndoPep-MS

2/2

Mouse lethality bioassay

7/8
Course of illness, d, median (range)

Time to resolution

75 (16–180)

Duration of nasogastric tube support†

11 (10–27)

Duration of intubation‡

11.5 (2–21)

Duration of ICU stay§

10.5 (11–30)

Duration of hospitalization

16 (11–30)

Time to diagnosis

9.5 (4–35)

Table 2. Clinical features, diagnosis, and course of infant botulism patients, Israel, 2007–2021*

*EndoPep-MS, mass spectrometric–based endopeptidase assay for detecting and differentiating botulinum neurotoxin serotypes; ICU, intensive care unit.
†5/8 patients were supported by feeding tube.
‡2/8 patients were intubated.
§4/8 patients were admitted to ICU.

CME / ABIM MOC

Infant Botulism, Israel, 2007–2021

  • Authors: Bar Goldberg, MD; Dana Danino, MD; Yoel Levinsky, MD; Itzhak Levy, MD; Rachel Straussberg, MD; Halima Dabaja-Younis, MD, MPH; Alex Guri, MD; Yotam Almagor, MD; Diana Tasher, MD; Daniel Elad, DVM, PhD; Zina Baider, DVM; Shlomo Blum, DVM, PhD; Oded Scheuerman, MD
  • CME / ABIM MOC Released: 1/20/2023
  • Valid for credit through: 1/20/2024, 11:59 PM EST
Start Activity

  • Credits Available

    Physicians - maximum of 1.00 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 1.00 ABIM MOC points

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for infectious disease specialists and other clinicians who take care of patients who may develop infant botulism.

The goal of this activity is for learners to be better able to evaluate the epidemiology and risk factors for infant botulism.

Upon completion of this activity, participants will:

  • Analyze the epidemiology and prognosis of infant botulism
  • Assess characteristics of children with infant botulism in the current study
  • Evaluate risk factors for infant botulism in the current study
  • Assess outcomes of infant botulism in the current study


Disclosures

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All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.


Faculty

  • Bar Goldberg, MD

    Department of Pediatrics B
    Schneider Children’s Medical Center
    Petach Tikva
    Israel
    Sackler Faculty of Medicine
    Tel Aviv University
    Tel Aviv
    Israel

  • Dana Danino, MD

    Pediatric Infectious Disease Unit
    Soroka Medical Center
    Beer Sheva
    Israel
    Faculty of Health Sciences
    Ben-Gurion University
    Beer Sheva
    Israel

  • Yoel Levinsky, MD

    Department of Pediatrics B
    Schneider Children’s Medical Center
    Petach Tikva
    Israel
    Sackler Faculty of Medicine
    Tel Aviv University
    Tel Aviv
    Israel

  • Itzhak Levy, MD

    Department of Pediatric Infectious Disease Unit
    Schneider Children’s Medical Center
    Petach Tikva
    Israel
    Sackler Faculty of Medicine
    Tel Aviv University
    Tel Aviv
    Israel

  • Rachel Straussberg, MD

    Department of Pediatric Neurology Unit
    Schneider Children’s Medical Center
    Petach Tikva
    Israel
    Sackler Faculty of Medicine
    Tel Aviv University
    Tel Aviv
    Israel

  • Halima Dabaja-Younis, MD, MPH

    Pediatric Infectious Disease Unit
    Rambam Medical Center
    Haifa, Israel
    The Ruth & Bruce Rappaport Faculty of Medicine
    Technion
    Haifa
    Israel

  • Alex Guri, MD

    Pediatric Infectious Disease Unit
    Kaplan Medical Center
    Rehovot
    Israel
    Hadassah Faculty of Medicine
    The Hebrew University of Jerusalem

  • Yotam Almagor, MD

    Meuhedet Healthcare
    Israel

  • Diana Tasher, MD

    Pediatric Infectious Disease Unit
    Wolfson Medical Center
    Holon
    Israel
    Sackler Faculty of Medicine
    Tel Aviv University
    Tel Aviv
    Israel

  • Daniel Elad, DVM, PhD

    National Reference Laboratory for Botulism
    Kimron Veterinary Institute
    Bet Dagan
    Israel

  • Zina Baider, DVM

    National Reference Laboratory for Botulism
    Kimron Veterinary Institute
    Bet Dagan
    Israel

  • Shlomo Blum, DVM, PhD

    National Reference Laboratory for Botulism
    Kimron Veterinary Institute
    Bet Dagan
    Israel

  • Oded Scheuerman, MD

    Departments of Pediatrics B and Pediatric Infectious Disease Unit
    Schneider Children’s Medical Center
    Petach Tikva
    Israel
    Sackler Faculty of Medicine
    Tel Aviv University
    Tel Aviv
    Israel

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine

    Disclosures

    Charles P. Vega, MD, has the following relevant financial relationships:
    Consultant or advisor for: GlaxoSmithKline; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.

Editor

  • Jude Rutledge, BA

    Copyeditor 
    Emerging Infectious Diseases

Compliance Reviewer

  • Leigh Schmidt, MSN, RN, CNE, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Leigh Schmidt, MSN, RN, CNE, CHCP, has no relevant financial relationships.


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Interprofessional Continuing Education

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  • Medscape, LLC designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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CME / ABIM MOC

Infant Botulism, Israel, 2007–2021

Authors: Bar Goldberg, MD; Dana Danino, MD; Yoel Levinsky, MD; Itzhak Levy, MD; Rachel Straussberg, MD; Halima Dabaja-Younis, MD, MPH; Alex Guri, MD; Yotam Almagor, MD; Diana Tasher, MD; Daniel Elad, DVM, PhD; Zina Baider, DVM; Shlomo Blum, DVM, PhD; Oded Scheuerman, MDFaculty and Disclosures

CME / ABIM MOC Released: 1/20/2023

Valid for credit through: 1/20/2024, 11:59 PM EST

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Abstract and Introduction

Infant botulism (IB) is an intestinal toxemia that manifests as descending paralysis, constipation, and, in some cases, respiratory failure. Laboratory-confirmed IB cases are rare, and recent data in Israel are lacking. We conducted a national multicenter retrospective study of laboratory-confirmed IB cases reported in Israel during 2007–2021. A total of 8 cases were reported during the study period. During 2019–2021, incidence may have increased because of a cluster of 5 cases. Infant median age for diagnosis was 6.5 months, older than previously reported (3 months). Most cases occurred during March–July. Honey consumption was reported in 1 case, and possible environmental risk factors (living nearby rural or construction areas, dust exposure, and having a father who works as a farmer) were reported in 6 cases. Although IB is rare, its incidence in Israel may have increased over recent years, and its epidemiology and risk factors differ from cases reported previously in Israel.

Introduction

Clostridium botulinum is a gram-positive, rod-shaped, spore-forming, obligate anaerobic bacterium. It is ubiquitous in the environment, such as soil and marine sediment, and can be easily isolated from the surfaces of vegetables, fruits, and seafood. Botulinum neurotoxins (BoNTs) secreted by C. botulinum bacteria are among the most potent toxins in nature. BoNTs target motor neurons, and block the cholinergic neuromuscular innervation of striated and smooth muscles in multiple tissues. BoNTs are classified into 7 antigenic serotypes (A to G). Types A, B, and, rarely, E and F, are linked to infant botulism (IB). IB can occur when an infant ingests C. botulinum spores because of exposure to contaminated soil or agricultural products, notably honey, when the bacteria develop and release BoNTs into the intestine[1,2].

IB is a rare disease with a peak incidence among infants 2–8 months of age. IB is classically described as a flaccid descending symmetric paralysis, and recovery can take several weeks[3]. The disease manifests in a wide clinical spectrum, from mild symptoms to life-threatening conditions[3–8], and often leads to a late diagnosis[9,10]. The standard and the most sensitive and specific in vivo method used to confirm IB is by mouse lethality bioassay (MLB)[7]. Treatment includes monitoring, supportive management, and administration of antitoxin[11–13]. In the United States, the mortality rate among hospitalized infants is ≈1%[14].

Since 1976, at least 3,350 cases of IB have been reported worldwide, 90% of them in the United States, the highest reported incidence in California. Many cases probably are unrecognized or unreported[15–18]. The average incidence in the United States is 2.1 cases/100,000 live births[15], corresponding to ≈75–100 cases yearly[7].

Israel is a developed country with a high-quality and universally available healthcare system, and botulism diagnosis is conducted in a single centralized reference laboratory. Recent data on IB in Israel are lacking. The main goals of our study were to evaluate the current incidence of infant botulism in Israel and examine national epidemiologic and clinical data from the past 2 decades. The study was approved by the Institutional Review Board at the Rabin Medical Center (approval no. RMC 20–0972).