When doctors at a local community hospital were unable to diagnose a three-month-old baby’s illness, she was transferred to the Morgan Stanley Children’s Hospital at NewYork-Presbyterian/Columbia University Medical Center (MSCHONY), where she was quickly diagnosed with botulism and successfully treated.
The case was featured in a recent “Diagnosis” column in the New York Times Magazine. The following is a Q&A (condensed and edited) with two members of the clinical team involved in the baby’s care:
R. Stanley Hum, MD, is assistant professor of clinical pediatrics (in critical care) at Columbia University Medical Center (CUMC) and pediatrics attending at MSCHONY.
Pelton Phinizy, MD, P&S ’10, is a postdoctoral residency fellow at CUMC and a pediatrics resident at MSCHONY. In fall 2013, he will begin a fellowship in pediatric pulmonology at MSCHONY.
Q: How important was the clinical exam in making the diagnosis of botulism in this case?
Dr. Hum: The exam was very important. The other thing Dr. Phinizy did well was to get an appropriate history. Few conditions—examples include Guillain–Barré and some other metabolic syndromes such as encephalopathy—cause a previously healthy child of this age to have a sudden onset of weakness. And the other hospital had done several tests that had come back negative. Botulism jumped far up on the list.
Honey is the only known dietary source of botulism. When there is no history of having eaten honey, as was the case here, the diagnosis is more complicated. And you have to act quickly. Confirmatory tests take a few days, yet this child needed care immediately. The earlier you give the treatment—human botulism immune globulin intravenous (BIG-IV)—the better. We were lucky enough to see her early enough that no harm came to her.
Q: Is the clinical exam of particular importance in pediatric (as opposed to adult) critical care?
Dr. Phinizy: Pediatric patients can’t always tell you what’s wrong, although that can be true with adults, too. Children are not just little adults, is what we like to say. Everything is a little different—from how they get sick to how they respond to treatment. Our patients range from premature infants up to what are essentially adults, 18–21 year-olds; so we need to be able to interpret a wide range of physical exam findings. And examining 2-year-olds—distracting them enough to get an exam—is different from examining teenagers, who may require a lot of coaxing or cajoling to get them to give more than one-word answers.
Dr. Hum: There are a lot more laboratory tests and imaging we can do now, which certainly help with the diagnoses. But that doesn’t change the importance of the physical exam. In many cases, you can wait for test results to confirm a diagnosis. But in other cases—such as with baby Alice—time is of the essence. Then you count on the physical exam and history to make the best judgment you can.
Dr. Phinizy: As a doctor, you have to develop the right way of asking questions, of interpreting the patient’s—or family member’s—answers in context of the physical exam, and then knowing what follow-up questions to ask.
Dr. Hum: We’re privileged as physicians, and we are aware that we have to earn the patient’s trust. People come to us—total strangers—and tell us things they tell no one else, not even their own family. They know that it’s confidential and that we’re trying to help them. The key is to get the most accurate history possible from someone who may be under a lot of stress and may not remember everything perfectly.
To a greater or lesser degree, the history is what guides what you do. The history guides the physical examination, and both guide your laboratory tests.
Q: Will this be a case that you’ll remember throughout your career?
Dr. Phinizy: For me, definitely. Of course, I’m still building both my career and a memory bank of significant cases. This case was rare—we get maybe one case of botulism every year or so at the hospital. Also, I established a good relationship with the parents over the first few hours and continued to see them over the next few weeks, while they were in the hospital; so they’ll stick with me personally.
I also realized how hyper-alert I was. I was scared—appropriately so—about what was going on. At the same time, I felt confident that I could handle it; in addition to proceeding methodically, I felt good that I had the right gut reaction.
Dr. Hum: Yes, it was a rare illness. Also, a wonderful set of parents and the child did very well. In pediatrics, many children get very sick, but a good percentage do well, and that’s always gratifying. It’s nice to know that you’ve made a difference in a child’s, in a family’s, life.
Q: Is there anything you would like to add?
Dr. Hum: We need to acknowledge that a whole team saw this child—the interns who saw her when she came in; Dr. Phinizy and Dr. Paule Moureaux-Nery, his attending in general pediatrics; the nurses who helped the child upon intake and transferred her to the PICU; my PICU fellow, Dr. Steven Horwitz, who was the first to examine her in the PICU; my PICU resident; the PICU nurses; the pharmacists who helped us get the human immune globulin on a plane from California; the team that administered the treatment the next day; the team that cared for her throughout her PICU stay; the team that later cared for her on the general pediatrics floor; the respiratory therapists who set up her ventilator; and so on. This was a huge team effort. Dr. Phinizy and I just got lucky that they decided to focus on our names in the New York Times Magazine piece. Everyone involved in her care deserves as much credit as anyone else—and any one of our pediatricians could have made this diagnosis.