Clostridium difficile colitis associated with infant botulism: Near-fatal case analogous to Hirschsprung's enterocolitis

We present the first five reported cases of Clostridium difficile-associate d diarrhea (CDAD) in children with infant botulism caused by Clostridium bo tulinum. We compare two fulminant cases of colitis in children with colonic stasis, the first caused by infant botulism and the second caused by Hirsc hsprung's disease. In both children, colitis was accompanied by hypovolemia , hypotension, profuse ascites, pulmonary effusion, restrictive pulmonary d isease, and femoral-caval thrombosis. Laboratory findings included pronounc ed leukocytosis, hypoalbuminemia, hyponatremia, coagulopathy, and, when exa mined in the child with infant botulism, detection of C. difficile toxin in ascites. CDAD recurred in both children, even though difficile cytotoxin w as undetectable in stool after prolonged initial therapy. Four children who had both infant botulism and milder CDAD also are described. Colonic stasi s, whether acquired, as in infant botulism, or congenital, as in Hirschspru ng's disease, may contribute to the susceptibility to and the severity of C DAD.