A new case report published in Cureus* highlights the importance of recognising and treating iatrogenic botulism. Although iatrogenic botulism is rare, it is a potentially fatal illness if not treated appropriately. Data is sparse and there is limited awareness among medical professionals. Increased global use of botulinum toxin may lead to a rise in cases, raising concerns about the need for stricter regulations and oversight of botulinum toxin administration worldwide.
While botulinum toxin is widely used and generally considered safe, there is a rare but potential risk of iatrogenic botulism arising from the systemic circulation of the toxin. Diagnosing iatrogenic botulism is challenging and has been frequently misdiagnosed. Presenting symptoms include cranial nerve palsies, flaccid paralysis and respiratory depression.
This case report focuses on a 47-year-old female who experienced iatrogenic botulism after receiving botulinum toxin injections in Istanbul, Turkey and subsequently treated in the United States upon her return home.
Case presentation
The patient presented to the emergency department with blurred vision, difficulty swallowing, hoarse voice, shortness of breath and weakness. It was established that she had received botulinum toxin injections in her forehead and bilateral axilla three weeks earlier while in Istanbul, Turkey.
According to the report, forehead treatment involved 50 units of Dysport (abobotulinumtoxinA), and axillary treatment involved a total of 90 units of Dysport.
‘Her symptoms initially manifested as blurred vision and diplopia, progressing to include dysphagia and dysphonia,’ the authors note. Despite seeking care at an emergency department in Istanbul, she was discharged without a diagnosis. Upon returning to the United States, she presented to our facility with symmetric, progressive descending weakness and reported shortness of breath, although she was not in respiratory distress and remained hemodynamically stable.’
The case report states: ‘A detailed neurological examination revealed an alert and oriented patient without dysarthria, with a hoarse voice. Visual acuity was normal, with no observed visual field deficits or ophthalmoplegia, although mild bilateral ptosis was noted. Facial sensation was normal to light touch and pinprick, with minimal movement in the right frontalis muscle and absent movement on the left side. The patient’s hearing was grossly intact, with normal soft palate and tongue movement and a normal gag reflex. Muscle strength in the trapezius and sternocleidomastoid muscles was normal, except for bilateral iliopsoas weakness. The deep tendon reflexes in both upper and lower extremities were normal and symmetrical bilaterally, and the Babinski tests yielded negative results on both sides. Sensation to pinprick, light touch, and vibration in both hands and feet was normal, as were finger-to-nose, heel-to-shin, fine hand movement, and rapid alternating movement tests.’
Routine laboratory examinations, including a complete blood count and basic metabolic panel, revealed results within normal ranges. Testing for myasthenia gravis antibodies was negative, and the findings from the chest X-ray appeared normal.
‘A clinical diagnosis of iatrogenic botulism was established,’ the authors write. ‘Our team discussed the case with the Centers for Disease Control (CDC), and the antitoxin was promptly airlifted from Atlanta and delivered to our facility within hours. Meanwhile, the patient was admitted to the intensive care unit (ICU) for close monitoring until the antitoxin arrived. Her lower extremity weakness worsened during her ICU stay, making ambulation difficult. Her condition deteriorated before the administration of antitoxin.
‘Twelve hours after her initial presentation to the hospital, the patient received 198 mL of Botulism Antitoxin Heptavalent (A, B, C, D, E, F, G) in 0.9% normal saline, along with 20 mL of botulism immune globulin (Human) 100 mg IV SOLR 1,000 mg. She did not experience any reported adverse reactions. Clinical improvement was observed almost immediately after the administration of antitoxin. She was observed in the ICU for one day and discharged on hospital day 2. The patient was followed up with one month after discharge and remains symptom-free.’
Diagnosing botulism ‘exceptionally challenging’
The authors note that diagnosing iatrogenic botulism is exceptionally challenging for healthcare providers. They write: ‘This difficulty stems from the disease’s rarity, limited awareness among medical professionals, and the absence of readily available confirmatory tests. Recent literature reviews from 2017 reveal that botulism was frequently misdiagnosed as myasthenia gravis or Guillain-Barre syndrome. This difficulty stems from the resemblance in signs and symptoms shared by these conditions and botulism, coupled with their increased prevalence.
‘Additionally, there are no immediate laboratory tests to confirm the diagnosis. Serum and stool studies can be obtained, but often take several days to yield results. Thus, iatrogenic botulism is a clinical diagnosis and the healthcare provider must have a high index of suspicion.’
Certain clinical criteria, emphasising specific signs and symptoms of cranial neuropathy, combined with the absence of fever, can help with diagnosis.
‘We acknowledge the significant challenge in diagnosing this disease. Our case aims to inform healthcare providers about this lesser-known cause of botulism and to emphasise the importance of inquiring about recent Botox procedures in patients presenting with cranial nerve palsies and descending paralysis,’ the report says.
Botulism antitoxin, early treatment crucial
Botulism antitoxin consists of equine serum antibodies to botulinum toxins A-G and is the only specific treatment for botulism. The case study authors note that research from 2017 suggests that early antitoxin administration, within the initial 48 to 96 hours of symptom onset, correlates with lower mortality rates than delayed administration.
‘Despite our patient receiving antitoxin therapy eight days after symptom onset, her clinical condition rapidly improved post-treatment. In a 2016 case report by Fan et al, similar outcomes were observed, with two patients recovering swiftly from iatrogenic botulism after receiving antitoxin seven and nine days after the onset of symptoms,’ the authors state.
Increased botulinum toxin = increased botulism risk?
‘Although iatrogenic botulism remains rare, increased global Botox utilisation may lead to a rise in cases. Our experience underscores the importance of maintaining a high index of suspicion and obtaining thorough patient histories, particularly for those receiving treatment abroad. This vigilance is crucial for timely diagnosis and favourable patient outcomes.,’ the authors warn.
‘In the United States, regulation of Botox administration by the FDA aims to ensure safety; however, cases of iatrogenic botulism persist globally, particularly in countries with less stringent regulations. Our patient received Botox in Istanbul, Turkey, where previous cases of iatrogenic botulism have been reported. This case highlights the importance of revisiting regulations surrounding Botox administration in countries where oversight may be less strict.
‘…It is imperative to acknowledge the potential risks associated with Botox administration, particularly the rare but serious complication of iatrogenic botulism. As evidenced by our case, prompt recognition and treatment are essential for favourable patient outcomes. Healthcare providers, particularly emergency physicians, should maintain a high index of suspicion for iatrogenic botulism in patients presenting with symptoms suggestive of cranial nerve palsies and descending muscle weakness, especially when there is a history of recent Botox use. Obtaining a comprehensive patient history, including travel details, is crucial for accurate diagnosis and timely intervention.’
* Richardson J, Viviano S (February 12, 2024) From Beauty to Botulism: A Case Report Highlighting the Rare Risk of Botox Administration. Cureus 16(2): e54090. doi:10.7759/cureus.54090
