Thursday, September 28, 2023
| 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
| 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.
Physicians - maximum of 1.00 AMA PRA Category 1 Credit(s)™
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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.
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).
