What is Iatrogenic Botulism?

Botulism symptoms have been reported as occurring in at least 2-5% of patients following Botox injections for therapeutic purposes

Iatrogenic botulism (IB) is botulism that occurs following botulinum toxin injection (brands include Botox, Dysport, Xeomin, Daxxify, Jeuveau, etc.).

Iatrogenic botulism occurs on a spectrum, and can be categorized into mild, moderate, or severe forms. Research has shown that botulism symptoms can occur after cosmetic or therapeutic doses. Botulism symptoms can develop after injection from any brand or amount of botulinum toxin, even when patients receive injections from licensed and experienced injectors.

The Toxin Spread Warning states the following on all BoNT product inserts:

Iatrogenic botulism patients can present with a wide variety of symptoms, and will likely have at least 4-5 of the symptoms listed below. One of the earliest and most prevalent symptoms in iatrogenic botulism is sudden onset of extreme anxiety and even panic attacks, due to parasympathetic nervous system disruption. Unfortunately, the presence of this symptom can often result in providers dismissing botulism patients as experiencing psychosomatic symptoms.

According to the CDC, 83% of physicians misdiagnosed botulism, oftentimes mistaking it for myasthenia gravis, Guillain-Barre syndrome, or psychiatric disorders.

(Note that an IB diagnosis depends on ruling out other, similar diseases such as myasthenia gravis, stroke, meningitis, and Guillain-Barre Syndrome.)

Because there are no readily available objective tests for botulism (the mouse bioassay tests that are conducted at CDC headquarters are typically only valid if done in the first 24-48 hours post-toxin exposure), the most important factor to consider when determining if a patient has IB is onset of symptoms in relation to the time of injections (most patients will begin presenting with symptoms within 7 days following injections, but some symptoms can show up 3-6 weeks after injections.)

Detailed research and knowledge about iatrogenic botulism is hard to come by in the medical field, and because botulism symptoms are nervous system disruption that does not usually show up on tests at hospitals, many IB patients will fly under the radar and be discharged home without diagnoses.

Bai and colleagues (2018) documented the following symptoms as the most common in IB patients they followed who had received cosmetic injections (please note: this is not a complete list of potential botulism symptoms. A complete list can be found here):

Mild iatrogenic botulism: 

• headache

• dizziness

• fatigue

• blurry vision

• anxiety

• difficulty swallowing (including dry mouth and "globus" sensation)

• insomnia

• dysarthria (slurred speech)

• constipation

  
  

Moderate iatrogenic botulism: any of the above characteristics with moderate to severe dysphagia (aspiration actively occurring - need for NPO feeding)

Severe iatrogenic botulism: any of the above characteristics with additional need for mechanical ventilation

If patients are within 3 weeks of their botulinum toxin injections, every effort should be made to obtain antitoxin from the CDC, as even mild cases of botulism can turn moderate or severe within days.

The CDC's 24/7 Botulism phone number is: 770-488-7100

As medical providers, it is imperative that we are asking any patients who present with sudden onsets of these symptoms if they have received botulinum toxin injections in the past 2-4 weeks. While many people with mild or moderate botulism will heal on their own within 6-24 months, if their botulism is severe and not caught early, it can take years or even decades to heal. Patients should be advised by their doctors to stop all botulinum toxin injections if botulism is suspected, per the Botox product insert.

All medical professionals should be screening patients who present with multiple botulism symptoms (with no obvious cause) for recent use of botulinum toxin injections.

References:

Bai L, Peng X, Liu Y, Sun Y, Wang X, Wang X, Lin G, Zhang P, Wan K, Qiu Z. Clinical analysis of 86 botulism cases caused by cosmetic injection of botulinum toxin (BoNT). Medicine (Baltimore). 2018 Aug;97(34):e10659. doi: 10.1097/MD.0000000000010659. PMID: 30142749; PMCID: PMC6112997.

Botox product insert: https://www.rxabbvie.com/pdf/botox-cosmetic_pi.pdf?mibextid=2JQ9oc

CDC: About Botulism. https://www.cdc.gov/botulism/about/index.html