Increase awareness and vigilance among neurologists in recognizing and treating iatrogenic botulism.  

A 53-year-old female presented to the ER with rapidly progressing dysphagia and bilateral facial, proximal shoulder and pelvic girdle weakness. She had prominent, bilateral ptosis but did not have any pupillary abnormalities or autonomic dysfunction. She reported botulinum neurotoxin injection in her face 10 days prior to the onset of her symptoms. The neurotoxin was self-injected during a “Botox party” and was imported from China. Notably, she also had a cosmetic botulinum toxin injection of an FDA approved formulation 9 months earlier without any adverse effects.

A trial of pyridostigmine resulted in mild, transient improvement. Later, she developed respiratory muscle weakness with a negative inspiratory force of  -15cm H₂O. Myasthenia gravis antibody panel was negative. Three Hz repetitive nerve stimulation did not show a decremental response.  Worsening muscle weakness and respiratory involvement were discussed with the CDC.  Botulism antitoxin was administered on day 3 after onset of symptoms. Her respiratory function improved and mechanical ventilation was avoided.  However, she required PEG tube insertion because of persistent dysphagia. Over the next 2 months, she made a full recovery and her PEG tube was removed.

This case highlights a growing concern in the era of increasing access to and self-administration  of unregulated cosmetic neurotoxins. Early recognition and antitoxin administration can prevent respiratory failure, mechanical ventilation and unnecessary immunosuppressive therapy stemming from diagnostic confusion with myasthenia gravis. Stricter regulations and oversight of botulinum administration are needed.