Iatrogenic botulism in an amateur weight‐lifter

Abstract

Systemic weakness after appropriate therapeutic administration of botulinum toxin is an uncommon but recognized complication of treatment. 1,2 We describe an individual in whom it was possible to quantify the degree of systemic weakness produced by botulinum toxin to a highly unusual degree.A 34-year-old man was referred to the botulinum toxin clinic for treatment of his gait disorder. Enquiry revealed that the gait was first noted to be abnormal at 7 years of age with increasing abnormality throughout childhood and adult life. The patient described an intrusive tendency to trip and fall and an aching discomfort within the calves provoked in particular by prolonged standing. The remainder of the medical history and the family history were unremarkable.Despite his impairment, the patient pursued a variety of sporting interests in adult life including weight-lifting and, somewhat to our surprise, Thai boxing. Examination revealed the upper torso to be well muscled. The fundi, cranial nerves, and upper limbs were normal. The lower limbs were markedly hypertonic and hyperreflexic, with clonus at the ankles and an extensor plantar response but no certain weakness. Sensation was normal.Routine laboratory investigations, constituents of the cerebrospinal fluid, serum very long chain fatty acid concentration, and magnetic resonance imaging of the brain and spinal cord were normal. A diagnosis of idiopathic spastic paraparesis was made.In an attempt to improve heel strike and gait quality, 200 units of botulinum toxin type A (Dysport) were injected into single sites within the medial and lateral portions of both gastrocnemii and tibialis posterior on the right. The total dose used was 1,000 units (11 U/kg). The injections were guided by palpation and anatomical landmarks. At review, the patient reported significant improvement in the gait and lessening of his tendency to trip and fall. Indeed, so dramatic was the change, that the patient's mother was moved to tears when she met her son at a family gathering having not seen him for several months. The patient also reported a sense of fatigue and weakness occurring approximately 2 weeks after injection of botulinum toxin. He estimated that his weight-lifting abilities had transiently fallen to approximately 25% of their normal values. Twelve weeks after the first injection of botulinum toxin, the procedure was repeated. The total dose of Botulinum toxin type A (Dysport) was reduced to 600 units (7 U/kg). A total of 150 units of Botulinum toxin type A (Dysport) was injected into the medial and lateral portions of the gastrocnemii as was done previously. The tibialis posterior was spared. On this occasion, the patient was asked to keep a careful diary of his weight-lifting ability throughout the treatment cycle. The results are shown in Table 1. The table shows that limb strength fell to approximately 50% of baseline values after injection of botulinum toxin.Recurrent weakness with resolution over a period of approximately 12 weeks after each injection of botulinum toxin sugg...

Single-Fiber Electromyography Analysis of Botulinum Toxin Diffusion in Patients With Fatigue and Pseudobotulism

“…Pseudobotulism syndrome has previously been reported in the literature, sometimes with very serious consequences. [11][12][13][26][27][28][29][30][31][32][33] Symptoms (eg, fatigue, weakness, visual disturbances, difficulty swallowing, signs of autonomic nervous system [ANS] disturbance, abnormal SFEMG results) have been described. [11][12][13] In 3 case reports involving a total of 6 patients, SFEMG was used to confirm pseudobotulism, and abnormal results were found in 5 of the 6 cases.…”

Serious and Long-Term Adverse Events Associated with the Therapeutic and Cosmetic Use of Botulinum Toxin

“…The serious adverse events identified in case reports varied from idiosyncratic adverse reactions like anaphylactic shock to dose-dependent adverse reactions like cervical kyphosis and botulism [7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38]. They were attributed to various types and preparations of botulinum toxin.…”

“…In addition, botulism-like generalized weakness has been reported in a patient treated for axillary and palmar hyperhidrosis [12]. Serious adverse events related to the therapeutic use of botulinum toxin include severe velopharyngeal insufficiency, brachial plexopathy, remote muscle weakness, botulism-like generalized muscle weakness, necrotizing fasciitis, crisis of myasthenia, generalized paralysis, marked bilateral blepharoptosis, impairment of speech and chewing, Guillain-Barré syndrome, severe dysphagia, iatrogenic botulism, generalized skin rash, aspiration pneumonia, unilateral facial madarosis and alopecia, and palatal palsy [13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38]. It is interesting that one of the patients presented with generalized weakness 5 years after continued use of botulinum toxin [19].…”

Iatrogenic Botulism Outbreak in Egypt due to a Counterfeit Botulinum Toxin A Preparation – A Descriptive Series of Patient Features and Outcome

“…However, despite its well‐established safety, post‐injection adverse effects may occur, sometimes responsible for systemic toxicity due to the spread of the toxin beyond the injection site . To date, rare cases of iatrogenic systemic botulism have been reported .…”