The Case: 9mo M presenting with poor feeding, decreased stooling and sleepiness, found to have decreased tone and concern for respiratory failure during evaluation in ED.

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Discussion: The discussion for this case focused on 2 key aspects: work up and management of clinical deterioration while in the ED.

With regards to the work up, almost all fellows and attendings would obtain basic labs (CBC, BMP). A UA might be helpful given patient’s history of PICU admission for diarrhea and acidosis as he may have an underlying RTA. Dr. 

Agrawal argued for sending botulism with the initial work up given the concerning findings of poor feeding, constipation, and lethargy.

For additional imaging, some would also obtain an US given concern for possible obstruction on OSH XR and mental status changes concerning for intussusception. More fellows than attending would obtain an abdominal CT, likely because they were unclear about underlying pathology. In contrast, most attendings would not obtain additional abdominal imaging, as they were fairly confident that this was botulism.

On re-assessment the patient has progressively worsening tone and weakness. When PO challenged, he has a weak and discoordinated suck. His respiratory exam has also changed with increased work of breath and clear lungs. For next steps in management, many attending were concerned that intubation was indicated given rapid progression and concern that the patient will progress to apenea (and HFNC would not offer enough protection). With airway management, Dr. Kou stressed the importance of also having EtCO2 monitoring present.  Dr. Agrawal also raised the important point that succinylcholine should never be used in cases such as this with neuromuscular weakness (though many said that they would never use a paralytic in cases such as this).

Most in the room also agreed that with worsening weakness or progressive paralysis, neurology consult is warranted, even if the diagnosis of botulism is not obvious.

Denouement: Patient was admitted to the PICU on HFNC.  Head CT was normal.  Metabolic work-up showed a slight decrease in carnitine levels for which he was started on supplements, but was otherwise normal.  BG levels remained stable throughout admission.  A detailed dietary history was obtained, and it turns out 1-2 weeks prior to presentation the parents introduced a cereal that was coated in honey as well as crackers that were coated in honey.  He received baby BIg after which his tone and strength improved.  His stool studies did confirm infantile botulism.  After 2 weeks he was discharged home with PT/OT and continues to do well.

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