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Botulism

Botulism Symptoms Following Botulinum Toxin (“Botox”) Injections

There have been several cases in the U.S. of symptoms of botulism following botulinum toxin injections, often referred to as “Botox.” As of April 19, there have been three cases in New York City. All three people received an injection for cosmetic purposes and two of the three people were hospitalized. Most cases around the U.S. involve injections given by unlicensed or untrained individuals, counterfeit products, or services given in non-health care settings, such as homes and spas.

See your healthcare provider or go to the emergency room right away if you have any symptoms of botulism, including blurry or double vision, drooping eyelids, difficulty swallowing, difficulty breathing or muscle weakness. Call 911 if you need immediate help. If you have other new or concerning symptoms following a botulinum toxin injection that your provider did not explain were expected, get medical care immediately. Symptoms can begin days or weeks following a botulinum toxin injection.

If you plan to get a botulinum toxin injection, ask your provider if they are trained and licensed to give the injection, whether the product they are using is approved by the U.S. Food and Drug Administration (FDA) and where they purchased the product. FDA-approved products include Botox, Daxxify, Dysport, Jeuveau and Xeomin.

For more information:

Beware of Botulinum Toxin (“Botox”) Injections by Non-Medical Providers

CDC: Harmful Reactions Linked to Counterfeit "Botox" or Mishandled Botulinum Toxin Injections

FDA: Counterfeit Versions of Botox Found in Multiple States

Botulism is a rare but serious illness caused by a powerful poison called botulinum toxin, which is produced by a bacteria. The toxin attacks the body’s nerves and can lead to difficulty breathing, muscle weakness or paralysis and even death. Botulism occurs if a person ingests the botulinum toxin or if the bacteria grow in a wound or in the intestines and release the toxin. People with botulism cannot give it to others.

Types of Botulism

There are different types of botulism:

Foodborne botulism is caused by eating food contaminated with botulinum toxin. Common sources of foodborne botulism are homemade foods that have been improperly canned, preserved, fermented or refrigerated. Though uncommon, foods bought at a store can also be contaminated.

Infant botulism is the most common type of Botulism. It can happen when an infant ingests spores (young bacteria) of the bacteria that cause botulism. The spores are found naturally in soil or dust and inside homes on floors, carpet and countertops — even after cleaning. The spores can end up on the infant’s hands or objects that are then put in the infant’s mouth. For almost all children and adults who are healthy, ingesting botulism bacteria is not dangerous and will not cause botulism. In rare cases, infants get botulism when the spores grow into mature bacteria in their intestines, multiply, and produce botulinum toxin. It is most common in infants younger than 6 months old.

Wound botulism can happen when bacteria that causes botulism get into a wound, grow there, and produce the toxin. Wound botulism has occurred in people after a traumatic injury, such as a motorcycle accident, or surgery. People who inject drugs can get botulism if the drug (such as black tar heroin) is contaminated.

Iatrogenic botulism can happen after a botulinum toxin injection. Botulinum toxin products are used for cosmetic reasons (commonly called “Botox”), such as for wrinkles, or medical reasons, such as for migraine headaches. Legitimate products contain purified toxin and are approved by the FDA. People are more likely to develop botulism following a botulinum toxin injection if the product is counterfeit or administered incorrectly.

Adult intestinal botulism is the rarest type of botulism. Like infant botulism, can happen when spores of the bacteria that cause botulism are ingested, grow into mature bacteria in the intestines, multiply, and produce botulinum toxin. People who have serious health conditions that affect the gut may be more likely to get sick.

In the U.S., there are an average of 110 cases of botulism reported each year. About 25% of cases are foodborne and about 70% are infant botulism. In New York City, there are typically four to seven infant botulism cases reported each year.

Symptoms

With food-borne botulism, symptoms generally begin 18 to 36 hours after eating contaminated food. However, they can occur as soon as six hours or as many as 10 days after eating the contaminated food. For botulism caused by something other than food (such as botulinum toxin injections), symptoms may take days or weeks to develop.

Signs and symptoms might include:

Difficulty swallowing

Muscle weakness

Double vision

Drooping eyelids

Blurry vision

Slurred speech

Difficulty breathing

Difficulty moving the eyes

Possible signs and symptoms in foodborne botulism might also include:

Vomiting

Nausea

Stomach pain

Diarrhea

Signs and symptoms in an infant might include:

Constipation

Poor feeding

Drooping eyelids

Pupils that are slow to react to light

Face showing less expression than usual

Weak cry that sounds different than usual

Difficulty breathing

Floppy arms, legs or head

People with botulism might not have all of these symptoms at the same time.

The symptoms all result from muscle paralysis caused by the botulinum toxin. If untreated, the disease may progress and symptoms may worsen to cause full paralysis of some muscles, including those used in breathing and those in the arms, legs and torso.

If you or someone you know has symptoms of botulism, immediately go to a health care provider or emergency room. If you have difficulty walking, swallowing or breathing, call 911.

Diagnosis and Treatment

Botulism is usually diagnosed by finding the toxin in blood, or stool, or in the skin of people with wound botulism. Sometimes it can be found in contaminated food (if foodborne botulism).

If diagnosed early, botulism can be treated with a drug called an antitoxin, which prevents the botulinum toxin from causing any more harm. Antitoxin can only be given in a hospital. Antitoxin is not used to treat infant botulism; however, giving intravenous antibodies may be effective.

Severe botulism can cause respiratory failure and paralysis, which may require a patient to be on a breathing machine (ventilator) for weeks to months and may require intensive care. Depending on the severity of the illness, the paralysis can slowly improve over the course of weeks to months.

Prevention

There are ways to reduce the risk of botulism.

Foodborne Botulism

If you preserve, can or ferment your own foods, you can reduce the chance of these foods giving you, your family or friends botulism by:

Following safe home-canning instructions as recommended by the U.S. Department of Agriculture (USDA) in the USDA Complete Guide to Home Canning

Following all instructions for washing, cleaning and sterilizing items used in canning

Using pressure canners for low-acid foods like potatoes, most other vegetables and meats

Everyone can reduce their chances of getting botulism by:

Refrigerating any canned or pickled foods after you open them

Refrigerating homemade oils infused with garlic or herbs and throwing away any unused oils after four days

Keeping potatoes that have been baked while wrapped in aluminum foil hot (at temperatures above 140 degrees Fahrenheit) until they are served, or refrigerating them with the foil loosened.

Although safe for children and adults, honey should not be fed to infants because it may contain spores that cause botulism.

Iatrogenic Botulism

If you are getting a botulinum toxin injection, especially for cosmetic purposes, ask your provider if they are trained and licensed to give the injection, and whether the product they are using is approved by the FDA.

Wound Botulism

Prevent wound botulism by keeping wounds clean. Check for signs of infection such as redness, swelling, pus and fever. If a wound looks infected, get medical care right away.

Additional Resources

CDC: Botulism

NYS: Consumer Guide to Beauty Salons and Spas (PDF)