Administration Of Immune Globulin Research Articles

Hepatitis B virus surface antibody titers in babies administered hepatitis B immune globulin both intravenously and intramuscularly after birth

Objective: High rates of vertical transmission of hepatitis B virus (HBV) infection from carrier mothers to their babies are observed in hepatitis B e antigen (HBeAg)-positive mothers under the existing protocol. The current status suggests that the existing protocol may be insufficient for the prevention of mother-to-child transmission (MTCT) in HBeAg-positive mothers. To achieve complete prevention of HBV vertical transmission, we designed a protocol implementing intravenous administration along with ordinary intramuscular administration of HBV immune globulin (HBIG) to the baby after birth.Methods: We compared the HBV surface antibody (HBsAb) titer in babies who were simultaneously administered HBIG both intravenously and intramuscularly after birth with that in babies who received HBIG only intramuscularly.Results: The HBsAb titer rose rapidly after administration in the combined administration group, and the elevated titer was maintained for approximately 2 months. Although the antibody titer at the peak was nearly 6 times greater in the combined administration group than in the intramuscular administration group, the combined administration of HBIG did not have any effect on total IgG antibody levels in the bloodstream.Conclusion: The combined protocol was demonstrated to be safe and superior to the protocol of only intramuscular HBIG administration with respect to rapid elevation of HBsAb in the bloodstream. It could be an effective method for the prevention of MTCT in HBeAg-positive mothers.

Reverse genetics of rabies virus: new strategies to attenuate virus virulence for vaccine development.

Rabies is an ancient neurological disease that is almost invariably fatal once the clinical symptoms develop. Currently, prompt wound cleansing after exposing to a potentially rabid animal and vaccination using rabies vaccine combined with administration of rabies immune globulin are the only effective methods for post-exposure prophylaxis against rabies. Reverse genetic technique is a novel approach to investigate the function of a specific gene by analyzing the phenotypic effects through directly manipulating the gene sequences. It has revolutionized and provided a powerful tool to study the molecular biology of RNA viruses and has been widely used in rabies virus research. The attenuation of rabies virus virulence is the prerequisite for rabies vaccine development. Given the current challenge that sufficient and affordable high-quality vaccines are limited and lacking for global rabies prevention and control, highly cell-adapted, stable, and attenuated rabies viruses with broad cross-reactivity against different viral variants are ideal candidates for consideration to meet the need for human rabies control in the future. A number of approaches have been pursued to reduce the virulence of the virus and improve the safety of rabies vaccines. The application of reverse genetic technique has greatly advanced the engineering of rabies virus and paves the avenue for utilizing rabies virus for vaccine against rabies, viral vectors for exogenous antigen expression, and gene therapy in the future.

A Small Outbreak of Measles in 2013: In a Single Hospital in Northern Gyeonggi-do

Purpose: This study analyzed a small outbreak of measles at a single hospital located in northern Gyeonggi-do in 2013. Methods: We reviewed the medical records of measles patients at The Catholic University of Korea Uijeongbu St. Mary`s Hospital from August to October, 2013. Results: Fifteen children were confirmed to have measles by RT-PCR and serum IgM test; 1 neonate, 11 infants, and 3 toddlers. None of the patients had received Measles-Mumps-Rubella vaccination. All patients showed B3 type in viral genotyping. Nine children (60%) had been exposed to measles during treatment for other diseases in the pediatric ward. Incubation period was between 8 and 15 days. Fever started at a median 10 days after exposure and persisted for a median of 8 days. Rash showed at a median 13 days after exposure. Respiratory complications were observed in 40% of patients. Diarrhea developed in 53% of patients. Conclusion: Although measles has been well-controlled due to the high rate of vaccination coverage, it is possible to have an outbreak at any given time, especially in infants. We must learn from this outbreak, and remain fully aware of the possibility of reemergence and provide proper management, including vaccination or immune globulin administration, to infants exposed to measles. Reevaluation of serum IgG titer of neonates, infants, and pregnant women may be the first step to prevent further outbreaks.

Effectiveness of Varicella Zoster Immune Globulin Administration within 96 Hours versus more than 96 Hours after Exposure to the Varicella-Zoster Virus

목적: 고위험군 환자에서 수두 바이러스 접촉 후 예방 요법으로 수두 면역 글로불린을 투여한다. 두면역 글로불린으로 국내에서는 VZIG, 미국에서는 VariZIG®을 사용한다. 2013년 7월 미국 질병관리본부에서 수두 바이러스 노출 후 VariZIG®투여를 최대 10일까지로 연장하여도 수두 예방 효과가 있음을발표하였다. 본 연구에서 저자들은 수두 노출 후 96시간 이내에 VZIG 투여 군과 96시간 이후 투여군에서 수두 예방 효과를 비교하고자 하였다.방법: 삼성서울병원에서 2001년 1월부터 2012년 12월 사이에 VZIG이 투여된 환자들을 대상으로 향적차트 분석을 통해 평가하였다. 결과: 전체 91명의 환자에서 57명(62.6%)은 남자였고 연령의 중앙값은 5.91세였다. 39명(42.9%)은 병원 내에서 수두 바이러스에 노출되었다. 기저 질환은 고형 종양 41.8%, 혈액 종양 40.7%이었고 그외 다른 질환이 17.5%이었다. 전체 환자 중에서 45명(49.5%)은 조혈모세포 이식 환자였다. 74명(81.3 %)이 수두 바이러스 노출 후 96시간 이내에 VZIG을 투여 받았다. 수두 바이러스 노출 후 96시간 이내에 VZIG이 투여된 군과 96시간 이후에 투여된 군에서 수두 발생은 뚜렷한 차이가 없었다(2.7% vs. 5.9%, P =0.4664). 효소면역분석법 검사에서 수두 항체가 음성인 환자는 22명이었고, 이 환자들에서수두 바이러스 노출 후 96시간 이내에 VZIG이 투여된 군과 96시간 이후에 투여된 군에서 수두 발생은 뚜렷한 차이가 없었다(6.6% vs. 0%, P=0.667). 결론: 본 연구에 의하면 수두 노출 후 96시간 이전에 VZIG 투여군과 96시간 이후에 VZIG 투여군 사이에 수두 발생을 예방하는데 차이가 없었으나, 향후 더 많은 환자수에서 추가 연구가 필요할 것으로 사료된다.

The "Platelet Boilermaker" Is an Option for Quickly Raising Platelet Counts in IVIG Refractory ITP

Most patients with immune thrombocytopenia (ITP) respond to first line therapy. Rarely there are patients who remain with very low platelet counts despite administration of intravenous immune globulin (IVIG). A protocol at our institution (colloquially known as the "platelet boilermaker") for these refractory patients is to give 1 gram/kg of IVIG continuously over 24 hours concurrent with one unit of plateletpheresis product given over 6 hours repeated times 4. We examined the charts of 10 patients in the past 6 years who have received combined therapy. 70% were male; all were refractory to steroids and IVIG. Results are in table: Abstract 5023. TableAgeGenderDiseaseBleedingPlts PreDay +1Day+2Day+3Results65MEvansGIB1110510Stopped bleeding59MITP, CLLBruising3656No response34FITPPregnancy2583175150Delivered81FITPEpistaxis15384167Splenectomy day +123FITPEpistaxis552165Splenectomy day +164MDITPEpistaxis, ruising252427Stopped bleeding89MITPEpistaxis4655046Splenectomy day +157MITPBruising9586946Splenectomy day +128MITPICH14133325326No extension78MITPGIB27354498Splenectomy day +1Plt = platelet count x 109/LDITP = drug induced ITP, ICH - intracranial hemorrhage. GIB - gastrointestinal bleeding9/10 patients had at least a transient rise in platelets greater than 30x109/L - 5 patients underwent emergent splenectomy with no bleeding complications. The patient with ICH had no extension and while the other patients who responded had cessation of bleeding. In summary for patients with IVIG refractory ITP who either have bleeding or need urgent splenectomy combined continuous platelets/IVIG is a therapeutic option. DisclosuresOff Label Use: profilnine - warfarin reversal rVIIa - warfarin reversal.

It's time to phase in RHD genotyping for patients with a serologic weak D phenotype. College of American Pathologists Transfusion Medicine Resource Committee Work Group.

It's time to phase in RHD genotyping for patients with a serologic weak D phenotype. College of American Pathologists Transfusion Medicine Resource Committee Work Group.

Use of HBsAg Quantification to Guide HBIG Prophylaxis After Liver Transplantation.

Background: Hepatitis B surface antigen (HBsAg) quantification has recently been introduced to guide treatment in chronic HBV patients. Low HBV DNA (<2000 IU/mL) and HBsAg (<1000 IU/mL) levels can predict inactive carrier status and HBsAg loss in non-transplant populations. No information is currently available on use of HBsAg levels to guide HBV immune globulin (HBIG) administration after liver transplantation (LT). Materials and methods: Retrospective analysis of a prospectively collected database. Patients were included if: adults (≥18 years); recipients of a primary liver graft; HBsAg+ and HBV DNA- at transplantation; hepatitis C and/or HIV-; not transplanted for fulminant hepatic failure; on nucleoside analogs. All patients were administered 30,000 IU HBIG peri-operatively, and HBsAb was tested at day 7, 14, 28, and monthly thereafter. Further 30,000 HBIG were administered if HBsAb <100 mIU/mL on day 7 and/or HBsAg >100 IU/mL. Primary endpoint was efficacy of HBIG as percent of patients achieving HBsAg <100 IU/mL and HBsAb ≥100 mIU/mL at Day 7. Secondary endpoints were HBV recurrence, graft and patient survival at last follow-up. Results: 41 LT recipients transplanted between January 2011 and June 30, 2013 were included (mean age 53.6±7.8 years; males 78%). Hepatocellular carcinoma was present in 24 (58.5%) and hepatitis delta (HDV) infection in 19 (46.4%). HBsAg decreased from a mean of 1,070.8 (±2,654.8) IU/mL pre-transplantation to a mean of 304.1 (±845.4) at day 7 (p<0.0001). Seven (17.1%) patients did not achieve efficacy at day 7 and were boosted with additional 30,000 HBIG. A pre-transplant HBsAg level ≥1,000 IU/mL was the only predictor of efficacy of HBIG at day 7 post-LT (p =0.0002). At a mean of 16.8 (±6.7) months after LT, graft and patient survival are 100% and no case of HBV recurrence has been observed. Conclusions: A HBsAg titer ≥1000 IU/mL may be used to predict HBsAg loss in LT recipients undergoing HBIG prophylaxis. DISCLOSURES:De Simone, P.: Speaker's Bureau, Biotest Italy, Grifols.

Use of HBSAG Quantification To Guide HBIG Prophylaxis After Liver Transplantation

Hepatitis B surface antigen (HBsAg) quantification has recently been introduced to guide treatment in chronic hepatitis B virus (HBV) patients. No information is currently available on use of HBsAg levels to guide HBV immune globulin (HBIG) administration after liver transplantation (LT). We performed a retrospective analysis of a prospectively collected database. Patients were included if: adults (≥18 years); recipients of a primary liver graft; HBsAg-positive and HBV DNA-negative at transplantation; hepatitis C and/or HIV-negative; not transplanted for fulminant hepatic failure; on nucleoside analogues. All patients were administered 30,000 IU HBIG, perioperatively, and hepatitis B surface antibody (HBsAb) was tested at day 7, 14, 28, and monthly thereafter. A further 30,000 HBIG were administered if HBsAb &lt;100 mIU/mL and/or HBsAg &gt;100 IU/mL on day 7. The primary endpoint was the efficacy of HBIG as a percentage of patients achieving HBsAg &lt;100 IU/mL and HBsAb ≥100 mIU/mL at day 7. Secondary endpoints were performance of HBsAg levels in predicting HBsAg loss at day 7, HBV recurrence, graft, and patient survival at last follow-up. 41 LT recipients – transplanted between January 2011 and June 30, 2013 – were included (median age 54 years; male 78%). Hepatocellular carcinoma was present in 24 (58.5%) and hepatitis delta in 19 patients (46.4%); 7 (17.1%) patients did not achieve efficacy at day 7 and wereboosted with additional 30,000 HBIG. A pre-transplant HBsAg level ≥1,000 IU/mL was associated with 60-fold odds for failure at day 7 (p=0.0002). At a median follow-up of 14 months after LT, graft and patient survival were 100% and no case of HBV recurrence had been observed. Based on our results, we advocate the use of HBsAg titre to guide HBIG prophylaxis after LT.

Immune globulins and same-day thrombotic events as recorded in a large health care database during 2008 to 2012.

Thrombotic events (TEs) are rare and serious adverse events after administration of immune globulin (IG) products. Our study evaluated the occurrence of same-day TEs for different IG products and ascertained potential risk factors. This retrospective cohort study utilized HealthCore's Integrated Research Database (HIRD) to assess individuals exposed to IGs during 2008 to 2012. IG products were identified using recorded procedure codes and TEs were ascertained using ICD-9-CM diagnosis codes. The unadjusted same-day TE rates (per 1000 persons exposed) were estimated overall and by IG products, age, and sex. Multivariable logistic regression analyses were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for same-day TEs by IG products. Of 14,944 individuals exposed to IG products, 233 (15.6 per 1000 persons) had TE diagnosis code(s) recorded on the same-day as the IG exposure. Compared to Gammagard Liquid, Gammaplex (OR, 20.96; 95% CI, 2.45-179.33) and Vivaglobin (OR, 2.74; 95% CI, 1.19-6.32) users had a significantly increased same-day TE risk. Elevated, but nonsignificant TE risks were identified for Octagam, Gamunex, Privigen, and Lyophilized IG(s). An increased TE risk was also found with older age (≥45 years), prior TEs, and other health conditions. Our claims-based cohort study suggests a potentially elevated TE risk with different IG products and shows importance of recipient factors such as older age, previous TE, hypercoagulable state(s), and other health conditions. The results of this study suggest the need for continuous evaluation of procoagulant activity and manufacturing processes for IG products to further assure their safety.

Risk factors associated with immunoprophylaxis failure against mother to child transmission of hepatitis B virus and hepatitis B vaccination status in Yunnan province, China

ObjectiveTo explore the risk factors associated with immunoprophylaxis failure against mother to child transmission of hepatitis B virus (HBV) and hepatitis B vaccination status in Yunnan province, China. MethodsMulticenter cluster sampling was used to select pregnant women who were positive for hepatitis B surface antigen (HBsAg). HBV immunoprophylaxis was carried out for the newborns. Blood samples were collected and tested for HBV markers from 7 to 10 month old infants. The factors were analyzed by univariate and logistic regression. ResultsA total of 2765 mothers and their infants were enrolled. The failure rate of prevention of mother to child transmission (PMTCT) was 4.12%. The rate of timely HepB1 vaccination within 24h was 98.04%, the rate of three-dose vaccination was 92.30% and the rate of hepatitis B immune globulin (HBIG) administration was 68.97%. Place of residence, maternal education, gestational age and birth weight were related to administration of HBV immunoprophylaxis. It was remarkable that the rate of HBIG administration of infants was only 63.89% with whose mothers were both HBsAg and hepatitis B e antigen (HBeAg)-positive. Further analysis showed that there were three risk factors associated with HBV immunoprophylaxis failure: mothers who were positive for HBsAg and HBeAg, maternal HBVDNA level, and HBIG administration or not. ConclusionsPMTCT of HBV was well implemented in Yunnan. However, in order to achieve optimal prevention of vertical HBV transmission, it is mandatory to make additional efforts to improve the implementation of regulatory HBV immunoprophylaxis, especially for HBsAg-positive pregnant women.

Human rabies in Iran

Like most Asian and African countries, Iran is highly endemic for rabies, which is a preventable disease with the timely utilisation of post-exposure prophylaxis (PEP). With the availability of affordable vaccination in Iran, there are still several rabies deaths which are assumed misdiagnosed or received ineffective PEP. We reviewed the files of 16 human rabies deaths, consisting of two groups: 1, ineffective treatment; and 2, erroneous PEP. Most of the studied cases were male and were from rural areas. Stray dogs were found to be the common biting animal (68.75%). Of the patients, 10/16 (62.5%) who had injuries on their head and/or face demonstrated shorter incubation periods. The incubation period was longer in a 4-year-old boy who sustained injuries in his abdomen and back. All the patients in group 1 received four doses of vaccine and administration of human rabies immune globulin (HRIG), and death occurred with the mean of 49 days after the bite. This mean was 27 days in three patients in group 2, who received vaccine without administration of HRIG. In a total of 1,188,579 cases of PEP given in Iran during: 2002-2011, it is not known whether all PEPs were correctly administered by World Health Organization standards. Extending rabies awareness programmes and timely PEP education in the community in accordance with the implementation of rabies control measures might lead to a decrease in these unfortunate scenarios and heavy financial burden of vaccination required due to the prevalence of rabies.

Infant Botulism and Indications for Administration of Botulism Immune Globulin

Infant Botulism and Indications for Administration of Botulism Immune Globulin

Infant Botulism and Indications for Administration of Botulism Immune Globulin

Infant botulism is caused by the ingestion of Clostridium botulinum spores and leads to a life-threatening descending motor weakness and flaccid paralysis in infant children. This disease presents with symptoms such as constipation, weakness, and hypotonia and can lead to respiratory failure. Botulism immune globulin (BIG) was created to treat this deadly disease and functions by neutralizing all systemically circulating botulism toxins. It is indicated in children with clinically diagnosed infant botulism, before diagnostic confirmation, and has been shown to lead to a significant reduction in intensive care unit and hospital stay for these patients. This review article discusses the epidemiology, clinical presentation, history of BIG, and indications for administration of BIG.

Use of rabies immune globulin in seven urban emergency rooms in Pakistan

Abstract Background: Human rabies is a fatal infectious disease that is entirely preventable if correct and timely postexposure prophylaxis is given. Unfortunately, rabies immune globulin (RIG) administration, a life-saving biological, is often avoided by Emergency Room health care providers (HCPs). Objective: To understand the practices of HCPs for administration of RIG in severe dog-bite exposures, which are common causes of emergency room visits in Pakistan. Methods: A cross-sectional study was conducted among 103 HCPs working in seven hospitals in three cities of Pakistan. Results: Of 103 HCPs who responded to the questionnaires, 97.1% had administered rabies vaccine and 31.1% had administered ERIG in the past three years of their practice; three quarters said they would prefer to use HRIG if available; 35% said they would not inject wounds at all, 24.3% would only vaccinate a patient with severe dog bites, but not administer RIG. More than 55% were concerned about the cost of human and equine RIG. Conclusion: Although there is awareness about use of RIG, this life saving biological is grossly underused because of poor availability in Emergency Rooms (ERs) even though stocked by local dealers. Animal bite centers must make RIG available for severe exposures.

Caesarean section to prevent transmission of hepatitis B: a meta-analysis.

Vertical transmission of hepatitis B virus (HBV) occurs in up to 10% to 20% of births. To assess whether Caesarean section, compared with vaginal delivery, prevents HBV transmission. A systematic review and meta-analysis was conducted. Two investigators independently searched PubMed, EMBASE and other databases for relevant studies published between 1988 and 2013. A manual search of relevant topics and major conferences for abstracts was also conducted. Randomized trials, cohort and case-control studies assessing the effect of delivery mode on vertical transmission of HBV were included. Studies assessing antiviral therapy and patients with coinfection were excluded. The primary outcome was HBV transmission rates according to delivery method. Of the 430 studies identified, 10 were included. Caesarean section decreased the odds of HBV transmission by 38% compared with vaginal delivery (OR 0.62 [95% CI 0.40 to 0.98]; P=0.04) based on a random-effects model. Significant heterogeneity among studies was found (I²=63%; P=0.003), which was largely explained by variation in hepatitis B immune globulin (HBIG) administration. Meta-regression showed a significant linear association between the percentage of infants receiving HBIG per study and the log OR (P=0.005), with the least benefit observed in studies with 100% HBIG administration. Subgroup analysis of hepatitis B e-antigen-positive women who underwent Caesarean section did not show a significant reduction in vertical transmission. Caesarean section may protect against HBV transmission; however, convincing benefit could not be demonstrated due to significant study heterogeneity from variable HBIG administration, highlighting the importance of HBIG in HBV prevention. More high-quality studies are needed before any recommendations can be made.

Recent developments in diagnosis and management of bacterial sepsis in premature infant

Sepsis in premature is a major cause of morbidity and mortality.The definition of neonatal sepsis is complicated by the frequent presence of noninfectious conditions that resemble those of sepsis,especially in very low-birth-weight preterm infants.Although growth of an organism from a sterile site is the gold standard for definitive diagnosis,the positive rate is low.Therefore,assessment of history,risk factors,sepsis screening scores in combination with diagnostic tests are used to identify neonates who are more likely to be infected.Methods studied to prevent infection include improved hand hygiene,early feedings,immune globulin administration,prophylactic antimicrobial administration.It improves prognosis for early diagnosis and antibiotic administration. Key words: Bacterial sepsis; Diagnosis; Treatment; Premature infant

Transmission of Vaccinia Virus, Possibly Through Sexual Contact, to a Woman at High Risk for Adverse Complications

Severe adverse events, including eczema vaccinatum (EV), can result after smallpox vaccination. Persons at risk for EV include those with underlying dermatologic conditions, such as atopic dermatitis. We investigated a case of vaccinia infection, possibly acquired during sexual contact with a recently vaccinated military service member, in a female Maryland resident with atopic dermatitis. The U.S. Department of Defense's Vaccine Healthcare Centers Network (VHCN) and the Centers for Disease Control and Prevention (CDC) worked in conjunction with the patient's physician and the Maryland Department of Health and Mental Hygiene (DHMH) to confirm the diagnosis, ensure treatment, and prevent further transmission. Specimens collected from the patient were tested at the DHMH laboratories and were positive by real-time polymerase chain reaction for nonvariola orthopoxvirus. Testing at the CDC verified the presence of vaccinia-specific DNA signatures. Continuing spread of the patient's lesions led to the administration of vaccinia immune globulin and strict infection control measures to prevent tertiary transmission to vulnerable family members, also with atopic dermatitis. VHCN contacted the service member to reinforce vaccination site care and hygiene. This case underscores the importance of prevaccination education for those receiving the smallpox vaccine to protect contacts at risk for developing severe adverse reactions.

Revised 4-Dose Vaccine Schedule as Part of Postexposure Prophylaxis to Prevent Human Rabies

There is overwhelming evidence that the 4-dose vaccine schedule as part of postexposure prophylaxis to prevent human rabies for previously unvaccinated persons, as recommended by the Advisory Committee on Immunization Practices, United States in 2009, is safe and effective. When used appropriately with timely wound care and administration of human rabies immune globulin, the administration of 4 doses of vaccine on days 0, 3, 7, and 14 is likely to induce an adequate,long-lasting antibody response that is able to neutralize rabies virus and prevent disease in exposed patients. There has been no change in the recommended regimen for pre-exposure prophylaxis and for postexposure prophylaxis of previously vaccinated persons or for immunosuppressed patients.

Local public health response to vaccine-associated measles: case report

BackgroundThe most appropriate public health approach to vaccine-associated measles in immunocompromised patients is unknown, mainly because these cases are rare and transmission of vaccine-associated measles has not been previously documented. In this case report, we describe Peel Public Health’s response to a vaccine-associated measles case in an immunocompromised child in Ontario, Canada.Case presentationA five-year-old Canadian-born boy with a history of a hematopoetic stem cell transplant three years previously received live attenuated measles, mumps, and rubella (MMR) vaccine. Over the subsequent 7 to 14 days, he developed an illness clinically consistent with measles. There was no travel history or other measles exposure. Serology and polymerase chain reaction (PCR) testing confirmed acute measles infection. Following discussion with pediatric infectious diseases specialists, but prior to the availability of virus sequencing, it was felt that this case was most likely due to vaccine strain. Although no microbiologically confirmed secondary cases of vaccine-associated measles have been previously described, we sent notification letters to advise all contacts of measles symptoms since the likelihood of transmission from an immunocompromised patient was low, but theoretically possible. We decided to stratify contacts into immune competent and compromised and to deal with the latter group conservatively by excluding them as if they were exposed to wild-type measles because the risk of transmission of disease in this population, while presumably very low, is unknown. However, no contacts self-identified as immunocompromised and there were no secondary cases. Subsequent genotyping confirmed that this case was caused by vaccine strain measles virus.ConclusionThe public health approach to contact tracing and exclusions for vaccine-associated measles in immunocompromised patients is unclear. The rarity of secondary cases provides further evidence that the risk to the general public is likely extremely low. Although the risk appears negligible, exclusion and administration of immune globulin may be considered for susceptible, immunocompromised contacts of cases of vaccine-associated measles in immunocompromised patients.

A 3-month-old Boy With Concomitant Respiratory Syncytial Virus Bronchiolitis and Infant Botulism

To the Editors: A 3-month-old boy with respiratory failure was admitted to the pediatric intensive care unit of a Northern California medical center in February 2011. The illness began 3 days earlier with progressively worsening lethargy, cough and stridor, decreased oral intake and decreased urine output. A review of systems was notable for decreased bowel movements in the past week and the presence of copious clear secretions from the infant’s nose and oropharynx. The infant was born at term with no complications, was exclusively breastfed other than a dropperful of chicken broth given when the child was ill in the days before admission and had received no vaccines. A nasal aspirate polymerase chain reaction was positive for respiratory syncytial virus. Over the next 4 days, ventilatory settings were weaned as oxygenation normalized. The child was extubated twice, but each time developed hypercapnia requiring reintubation. Seven days after admission, the infant remained intubated and ventilated with poor respiratory effort. Neurologic examination revealed a nearly complete bilateral ptosis; facial diplegia with tears produced under stimulation and no facial grimace. Infant botulism was suspected. Stool was sent for Clostridium botulinum toxin, and botulism immune globulin was administered empirically. Two days later, stool tests revealed C. botulinum toxin type A and the diagnosis of infant botulism was confirmed. During the next 3 weeks, the child received nasogastric feeds and ventilatory support and slowly regained bulbar strength. He was extubated 9 days after botulism immune globulin administration and was discharged to home 1 month after admission with a mixed breastfeeding/tubefeeding regimen. He required supplemental oxygen by nasal cannula until 2 days before discharge. On discharge, the child was still noted to have decreased tone, a weak cry and mildly uncoordinated feeding mechanics. Infant botulism results from ingestion of spores of Clostridium species, which germinate and colonize the infant intestine, producing botulinum toxin. This toxin is absorbed and causes a descending, symmetric paralysis. Constipation is almost always the first sign of illness and is often overlooked (as in the case above).1 Diagnosis is confirmed by identification of C. botulinum organisms in the feces of an infant with a presentation consistent with the disease. Supportive care forms the cornerstone of therapy, though specific treatment has been available in the form of intravenous human botulism immune globulin since 1992, through the California Department of Public Health. Botulism immune globulin should be initiated as early as possible in the course of illness and should not be delayed for laboratory confirmation. Acute coinfection with respiratory syncytial virus and Clostridium spp. has not previously been described. This case serves to demonstrate the necessity to maintain an open differential diagnosis even when presented with laboratory confirmation of an apparent causative etiology. Kevin K. Quinn, MD James D. Cherry, MD, MSc Division of Pediatric Infectious Diseases UCLA David Geffen School of Medicine Neeta R. Shah, MD Laura J. Christie, MD Department of Pediatrics Kaiser Permanente Northern California Oakland, CA