Iatrogenic botulism resulting from the substantial increase in use of botulinum neurotoxin type A (BoNT-A) treatment is rarely reported. We aimed to describe a large iatrogenic botulism outbreak in Egypt in June-July 2017. Nine patients developed botulism after receiving intramuscular injections of BoNT-A (dose: 200-300 IU) to treat cerebral palsy (N = 7), spastic dystonia (N = 1) and hyperhidrosis (N = 1). Detailed findings were available in five of nine cases. Patients were admitted to the hospital 5-10 days after the BoNT-A injection. Complaints included muscle weakness in the upper and lower limbs (N = 5), dysphagia (N = 5), dizziness (N = 2), dyspnoea (N = 2), dysphonia (N = 2), dysarthria (N = 2), fatigue (N = 1), diplopia (N = 1) and blurred vision (N = 1). Physical examination showed bilateral ptosis (N = 5), diminished gag reflex (N = 2), ophthalmoparesis (N = 1), facial paresis (N = 1) and tongue weakness (N = 1). Diagnosis was based on the patients' history and presentation and did not require any confirmatory test. On hospital admission, patients received supportive care and trivalent botulism type A/B/E antitoxin (250-500 IU) was started. No patient required mechanical ventilation. Immediate reversal of the most severe features was observed while varying degrees of peripheral muscular weakness persisted. Full recovery required 6-12 weeks. Cases were promptly reported to the Egyptian health authorities, and epidemiological investigations revealed that the outbreak was related to a recently imported highly concentrated unlicensed BoNT-A preparation sold as Neuroxin . Immediate withdrawal from the market was ordered. In conclusion, iatrogenic botulism outbreak due to counterfeit botulism toxin may result in life-threatening features. The early administration of botulism antitoxin in addition to supportive care is life-saving. Clinicians should remain mindful of the risk of systemic botulism with BoNT-A therapy.

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Background: Drug abuse became an alarming problem in the last years in Egypt and many other countries. Some studies had examined the prevalence of substance abuse among school and university students, but few have assessed workers in workplaces which can pose major risks to the health and productivity of workers. The aim of this work is to estimate the prevalence of substance abuse among a sample of workers, to explore various behavioral and psychological manifestations. Methods: This is a cross - sectional study performed in one of the brick industries in Giza governorate in Egypt. It included 481 workers from different sections in the industry. Data were coded and entered using the statistical package for the Social Sciences (SPSS) version 25. The mean age of the participants was 34.85 ± 13.50 with a minimum of 6 years and maximum 87 years old. Results: Results showed high prevalence of various psychosocial problems among workers which were highest between 21 and 40 years old. Symptoms included poor concentration, depression, stress, suicidal and guilty thoughts, mood swings, aggressive behavior, anxiety and disturbed social relationships. Concerning abuse pattern, 47.3 % of employees were abusing cannabinoids, 19.2 % were abusing tramadol and 8.3 % were abusing both. Workers performing physical work recorded the highest rate of abuse. In addition, 50.5 % of workers are smokers which was the highest independent variable related to substance abuse. Conclusions: It is important to develop substance abuse policy, raise awareness regarding their health effects and serious impacts on individual’s physical, psychosocial and behavioral integrity. Drug testing in workplace is a must to ensure community safety.