Abstract Introduction Botox injections are used for a variety therapeutic purposes. While injections generally considered safe, serious complications could arise depending on injection site and technique, one of these is the chest wall with the most common complication being infection and rarely pneumothorax.This case report, presents a Botox injection complicated by pneumothorax and acute hypoxic respiratory failure in a patient on nocturnal Continuous Positive Airway Pressure (CPAP). Case presentation A 43-year-old male with mixed connective tissue disease complicated by spinal collapse at C1-C2 and subsequent spastic tetraparesis receiving Botox injections, with obstructive sleep apnea managed by nocturnal CPAP. He presented with acute onset of chest pain and shortness of breath following a recent Botox injection to left pectoralis muscle group. Chest X-ray revealed large left pneumothorax and mediastinal shift. Chest tube was placed, and subsequent Computed tomography angiography showed small residual left pneumothorax and trace paraseptal emphysema in the left lung apex. Next morning Rheumatology consultation excluded connective tissue disease relation to the presentation. At night patient continued to use his CPAP. At midnight he experienced clinical deterioration, repeated imaging demonstrated recurrence of pneumothorax. He was transferred to ICU and placed on bi-level positive airway pressure with no improvement, subsequent intubation attempt failed requiring cricothyrotomy following which patient suffered from cardiac arrest. Resuscitation lasted for 11 minutes with the return of spontaneous circulation. He was transferred to operating room for tracheostomy and bilateral large-bore chest tubes placement. Invasive Mechanical ventilation was initiated. Cardiothoracic surgery were consulted and they recommended continuation of chest tube suction, with low suspicion of bronchopleural fistula. Over the following days, the patient’s condition gradually improved, with radiological evidence of resolving pneumothorax. He was transferred to step-down unit on day 6 with last chest tube being removed on day 10. He was ultimately discharged after 31 days to long-term acute care. Discussion Previous literature review mentioned post botox injection complications such as pneumothorax and respiratory depression but this case is notable due to the combination of risk factors such as obstructive sleep apnea with nightly CPAP use ,spastic tetraparesis and difficult intubation.This report emphasizes the importance of anticipating potential respiratory complications in high risk patients and implementing early intervention strategies. It also highlights the challenges of managing pneumothorax in patients using CPAP, including the role of suction management, and the coordinated involvement of cardiothoracic surgery, ICU, and respiratory teams. This abstract is funded by: None
Soliman et al. (Fri,) studied this question.