It's one of the rarest infectious diseases, affecting an average of only 100 babies a year in the United States, but infant botulism infected two babies living on the same street at Fort Meade in recent months - puzzling researchers.
Clusters of the illness are not unprecedented, experts say, and the ubiquity of the bacterial spores that cause infant botulism makes isolating one source almost impossible.
That is especially true in this case, where the military base also happens to be an Environmental Protection Agency Superfund site.
Both children survived the illness, but one family confirmed yesterday that it has hired a lawyer who will likely sue the Army, claiming that military officials have been negligent in seeking the cause of the outbreak. The parents of the other child say they do not blame the military and do not plan to join a lawsuit.
On Thursday, base officials confirmed that both cases, the first diagnosed in October and the second in December, came from the same strain of Clostridium botulinum bacteria.
"I would be hesitant to reassure everyone by saying this is a freak thing and this is over," said Col. Bruno Petruccelli, a physician and director of epidemiology and disease surveillance at the U.S. Army Center for Health Promotion and Preventive Medicine in Aberdeen. "Maybe there will be a third case and a fourth case. We can't say there won't be another one."
Army doctors involved in the investigation say they have followed medical protocol, conducting an investigation with help from experts at the Centers for Disease Control and Prevention in Atlanta, Walter Reed Army Medical Center, Maryland Public Health Administration and Anne Arundel County Department of Public Health.
Infant botulism develops in newborns - usually those between 3 weeks and 6 months of age - when they ingest bacteria that produce a toxin inside the large intestine. The toxin attaches to nerves in the body and paralyzes them. Although the condition is treatable and most babies eventually recover, it causes several frightening symptoms, including paralysis and respiratory problems.
Such was the case with Jonathan Cook, now 10 months old, whose family lives on the Anne Arundel County military base.
On Oct. 2, Christine Cook noticed that the baby became fussy and was not feeding well. Thinking he was teething, she put him to bed. The next morning, he made an odd, grunting sound, and when she picked him up, his head flopped.
She took him to Bethesda Naval Hospital, where doctors, thinking Jonathan was dehydrated, gave him fluids intravenously. When his eyes began to gloss over, Cook recalled, Jonathan was rushed to Walter Reed Army Hospital, where a young physician noticed symptoms of infant botulism she had seen in a case during her residency.
She went home to research the condition and in the meantime, doctors tested him for meningitis. When that came back negative, they sent him to get a CT scan to rule out a neurological disorder. During the scan, Jonathan's vital signs plunged, and a gaggle of doctors and nurses rushed into the room, reviving him and putting him on oxygen.
Once infant botulism was definitively diagnosed, they treated him with a drug called "Baby-BIG," which slightly relieves symptoms and doesn't allow the toxin to paralyze any other nerves.
"My son was so sick, he couldn't even open his eyes," Cook said. "He had over 50 needle marks in him because his veins kept busting. To watch that, it was absolutely the most terrifying, horrible experience I've had to go through as a mother, and I've got four kids. I don't want any other families to have to go through that."
Jonathan has been fine since his recovery, but his mother became angry when, on Jan. 9, a Walter Reed doctor called her to say another child on her street had been diagnosed with infant botulism. At that point, she became convinced that the military was not committed to finding a cause.
Michael Archuleta, a Texas-based lawyer who is also a physician and is representing the Cook family, said he believes a pile of debris, about a block from the street where both families live, is the source of the toxin, and will file a negligence claim with the Army.
"We have two cases of infant botulism occurring in the same time frame, very close to one another, that is epidemiologically very improbable unless it came from an external or environmental source," he said.
A base spokeswoman confirmed that there was a debris pile and said it was removed and the site was covered with hay on Jan. 7.
The mother of the second child, who asked not to be identified when contacted by The Sun, said that her daughter is no longer sick and that she does not wish to join any potential lawsuit.
In interviews with both families, investigators have determined that the source was not food such as honey, which has proved to be a source of infant botulism.
Fort Meade and Army officials, as well as several leading independent epidemiologists and infectious disease experts, insist that testing soil in infant botulism cases would be fruitless because the bacterial spores that cause it are common and naturally occurring.
Dr. John Bartlett, a professor of medicine at the Johns Hopkins University who specializes in infectious diseases but is not involved in these cases, said that testing soil is "pointless."
"That kind of activity just doesn't pay off," he said. "You don't look for it in dirt, and even looking for it in a food source is going to be a long shot. I mean, two cases in the same geographic area are unusual, but I wouldn't know quite how to go about finding a source. Usually, we don't try because we don't find it."
Archuleta and the Cooks believe that DNA testing could establish an exact match between the two cases and the dirt pile or other soils, and they intend to use that evidence in any litigation.
The toxin is too ubiquitous, Petrucelli, the Army epidemiologist, said, and the DNA-testing process too inconclusive. That Fort Meade was built on a landfill and is currently monitored by the Environmental Protection Agency would not have any impact, because those sites focus on chemical agents and other toxic substances, not naturally occurring substances, he said.
Dr. James Campbell, a pediatric infectious disease specialist at the University of Maryland School of Medicine, who is not involved in the case, said unlike food-borne botulism, which generally infects adults and which investigators almost always link to a food source, there is often no identified source for the infant variety.