infectious disease/botulism

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Question 1 / 3

686463876c78b8d82816dd2e

Pediatrics

infectious disease

botulism

Case History

A 5-month-old infant is admitted to the pediatric ward with a 36-hour history of progressive weakness, poor feeding, and decreased activity. The parents report the infant has been constipated for the past 3 days and seemed to have a weak cry earlier today. On examination, the infant is lethargic, with generalized hypotonia and diminished deep tendon reflexes. Pupillary responses are sluggish, and there is mild ptosis. Respiratory effort appears shallow. The infant was exclusively breastfed until 2 weeks ago when solid foods, including a small amount of honey mixed with cereal, were introduced. Lumbar puncture cerebrospinal fluid analysis reveals clear fluid, glucose level of 3 mmol/L (2-4), protein of 0.45 g/L (0.20-0.45), and a white blood cell count of 2 /mm3 (0-10). Complete blood count shows a white blood cell count of 9.0 x 10^9/L (4.0-12.0), hemoglobin of 115 g/L (105-135), and platelets of 300 x 10^9/L (150-450). Serum electrolytes are sodium 138 mmol/L (135-145), potassium 4.2 mmol/L (3.5-5.0), chloride 102 mmol/L (95-105), and bicarbonate 24 mmol/L (22-29). Creatine Kinase is 50 U/L (0-170). What is the most likely diagnosis and the most critical initial management step beyond supportive respiratory and nutritional care?

Lab Parameter	Value	Reference Range
Fluid	Clear
Glucose level	3 mmol/L	2-4 mmol/L
Protein	0.45 g/L	0.20-0.45 g/L
White blood cells	2 /mm3	0-10 /mm3
White Blood Cell Count	9.0 x 10^9/L	4.0-12.0 x 10^9/L
Hemoglobin	115 g/L	105-135 g/L
Platelets	300 x 10^9/L	150-450 x 10^9/L
Sodium	138 mmol/L	135-145 mmol/L
Potassium	4.2 mmol/L	3.5-5.0 mmol/L
Chloride	102 mmol/L	95-105 mmol/L
Bicarbonate	24 mmol/L	22-29 mmol/L
Creatine Kinase	50 U/L	0-170 U/L

A ) Meningitis; Initiate broad-spectrum intravenous antibiotics and antiviral agents.

B ) Infant botulism; Administer human botulism immune globulin (BabyBIG).

C ) Guillain-Barré Syndrome; Consider intravenous immunoglobulin (IVIG) or plasmapheresis.

D ) Neonatal transient myasthenia gravis; Administer pyridostigmine.

E ) Organophosphate poisoning; Administer atropine and pralidoxime.

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Question 2 / 3

686463876c78b8d82816dd2c

Pediatrics

infectious disease

botulism

Case History

A 4-month-old male infant presents to an urgent care clinic with a 2-day history of progressively worsening constipation and decreased oral intake. His parents note he has become unusually quiet, with a weak cry, and seems to have trouble holding his head up. They also report that his eyes appear "droopy," and he often chokes during feeds. His diet includes formula, supplemented occasionally with mashed fruits prepared at home, sometimes sweetened with a small amount of raw honey from a local farm. On examination, the infant is lethargic but arousable. His anterior fontanelle is soft and flat. He exhibits bilateral ptosis, a diminished suck reflex, and poor head control. His face is hypomimic, and his pupils are sluggishly reactive to light. Generalized flaccid hypotonia is prominent, and deep tendon reflexes are notably diminished. Respiratory effort appears adequate, but his cry is weak and muffled, and saliva pools in his mouth. Vital signs are within age-appropriate limits. Given this presentation, what is the most appropriate initial management strategy and the specific anticipated complication that requires vigilant monitoring?

Lab Parameter	Value	Reference Range
Hemoglobin	125 g/L	100-140 g/L
White Blood Cell Count	9.2 x 10^9/L	6.0-17.5 x 10^9/L
Platelets	350 x 10^9/L	150-450 x 10^9/L
Sodium	138 mmol/L	135-145 mmol/L
Potassium	4.1 mmol/L	3.5-5.0 mmol/L
Chloride	102 mmol/L	98-107 mmol/L
Bicarbonate	24 mmol/L	22-29 mmol/L

A ) Hirschsprung disease; necessitating rectal biopsy and potential surgical management.

B ) Transient neonatal myasthenia gravis; requiring anticholinesterase therapy and close observation for spontaneous resolution.

C ) Congenital hypothyroidism; indicated by a complete thyroid panel and initiation of levothyroxine replacement.

D ) Infant botulism; requiring prompt administration of Botulism Immune Globulin Intravenous (BIG-IV) and vigilant monitoring for respiratory failure.

E ) Infant botulism; managed primarily with supportive care including ventilatory support as needed and aggressive nutritional supplementation.

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Question 3 / 3

686463876c78b8d82816dd60

Pediatrics

infectious disease

botulism

Case History

A 9-month-old female infant is brought to a pediatric urgent care clinic by her parents due to a sudden change in her activity and feeding patterns over the past 12 hours. Initially, they noted her arms seemed weaker when she reached for toys, and she was less vocal. This morning, her parents observed that she was struggling to lift her head, and her cry was softer than usual. She has not had a wet diaper in several hours, despite regular fluid intake, and her last bowel movement was 3 days ago. On physical examination, the infant appears lethargic with diminished spontaneous movements. There is noticeable bilateral drooping of the eyelids and a sluggish response of her pupils to light. Her sucking reflex is extremely weak, and attempts to elicit a gag reflex yield minimal response. Respiratory efforts appear shallow, with intermittent periods of decreased effort. Auscultation of her lungs reveals clear breath sounds bilaterally. Cardiac exam shows a regular rate and rhythm with no murmurs. Abdominal exam is soft and non-tender, with decreased bowel sounds. Neurological assessment confirms generalized hypotonia, absent deep tendon reflexes, and a symmetrical, descending pattern of weakness, most pronounced in the proximal muscles. There are no signs of fever, rash, or meningeal irritation. Which of the following is the most likely diagnosis and what is the crucial immediate step in managing this patient's condition?

Lab Parameter	Value	Reference Range
White Blood Cell Count	8.5 x 10^9/L	5.0-15.0 x 10^9/L
Hemoglobin	118 g/L	100-140 g/L
Sodium	138 mmol/L	135-145 mmol/L
Potassium	4.1 mmol/L	3.5-5.0 mmol/L
Chloride	102 mmol/L	98-107 mmol/L
Bicarbonate	24 mmol/L	22-30 mmol/L
Glucose	4.5 mmol/L	3.3-5.6 mmol/L
Arterial pCO2	50 mmHg	35-45 mmHg
Arterial pH	7.30	7.35-7.45

A ) Myasthenia Gravis / Plasmapheresis

B ) Lambert-Eaton Myasthenic Syndrome / Amifampridine

C ) Guillain-Barré Syndrome / Intravenous Immunoglobulin

D ) Infant Botulism / Administration of Botulism Immune Globulin Intravenous (BIG-IV) and supportive care with close respiratory monitoring

E ) Spinal Muscular Atrophy Type 1 / Nusinersen

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