A review on iatrogenic botulism

Abstract

Background: With the flourishing application of botulinum toxin cosmetically and therapeutically is the emergence of iatrogenic botulism, a new type of botulism in addition to the traditional ones. Objectives: We aim at a comprehensive review of the clinical characteristics of iatrogenic botulism. Methods: The available publications are retrieved and studied. Results: Botulinum toxin blocks cholinergic transmission in the neuromuscular junctions and autonomic ganglia. The blockade can spread from the site of tissue injection to adjacent or sometimes far off structures, resulting in inadvertent disabling or even lethal effects. On literature review, weakness and dysphagia are the commonest complications of iatrogenic botulism, whereas ophthalmological and oropharyngeal symptoms are more prevalent in the cosmetic group and dyspnea in the therapeutic group. Antitoxin therapy is required in about 20% of the patients. Diagnosis of iatrogenic botulism is primarily clinical and should not be confused with the neurological diagnoses possessing similar clinical manifestations. Vigilance to the drug formulation, dosage, and administration during botulinum toxin injection are part of the preventive measures in minimizing the occurrence of iatrogenic botulism. Conclusion: While overlapping with the traditional types of botulism, iatrogenic botulism carries its unique clinical characteristics.

Iatrogenic Botulism: A Case Treated With Botulinum Antitoxin

“…3,7 It binds to free circulating toxin but cannot reverse the settled neurotoxicity. 4 Antitoxin induces recovery not only by binding of the free intravascular botulinum toxin but also by increasing acetylcholine release in neuromuscular junction. Antitoxin also may provide the redistribution of botulinum toxin from the receptors.…”

“…Antitoxin administration is considered effective when it is applied in the first 48 hours of the exposure 3,7 . It binds to free circulating toxin but cannot reverse the settled neurotoxicity 4 . Antitoxin induces recovery not only by binding of the free intravascular botulinum toxin but also by increasing acetylcholine release in neuromuscular junction.…”

How Does Botulinum Toxin Inhibit Itch?

“…All serotypes are neurotoxins, except for C2. Human botulism is known to be caused by serotypes A, B, E, and rarely F, while botulism in fish, birds, and non-human mammals is mainly caused by serotypes C1 and D [ 22 ]. Botulinum neurotoxin serotype A (BoNTA) is the most toxic substance known to man with an estimated intravenous lethal dose (LD50) of 1–2 nanogram per kilogram (ng/kg) in humans [ 23 ].…”

A Double-Edged Sword “BoNT” in Hospital Settings From European Region: Iatrogenic Botulism Warranting Enhanced Vigilance

“…The World Health Organization medical product alert from August 2022 had reported 5 falsified batches of a BoNT product detected in 5 countries, namely, Jordan and Turkey in May 2022, Kuwait and the United Kingdom in June 2022, and Poland in July 2022 3 . Studies have revealed that iatrogenic botulism can be due to increased frequency in dosage for therapeutic use, which needs close monitoring of unlicensed BoNT A product, and adverse effects are more for cosmetic use than for therapeutic use 4,5 . Recently, the public interest is more inclined toward its off-label cosmetics use, which leads to its erroneous use such as obesity treatment as in the case of the recent outbreak.…”

“…3 Studies have revealed that iatrogenic botulism can be due to increased frequency in dosage for therapeutic use, which needs close monitoring of unlicensed BoNT A product, and adverse effects are more for cosmetic use than for therapeutic use. 4,5 Recently, the public interest is more inclined toward its off-label cosmetics use, which leads to its erroneous use such as obesity treatment as in the case of the recent outbreak. These studies highlight that BoNT product either as unlicensed form or off-label indications leads to life threatening adverse effects, which needs to be strictly regulated at all levels for the appropriate use.…”