C53-14 An Unlikely Killer: Iatrogenic Botulism and Respiratory Paralysis as a Result of Botched Botox Injection

Introduction A 32-year-old female with no significant past medical history presented to the emergency department with a headache, fatigue, diplopia, disequilibrium, arthralgia, dysphagia, left hemiparesis, and ataxia. After gathering further history, the patient mentioned that a few weeks prior she received 42 microneedle counterfeit OnabotA injections. Post-admission, the patient started to develop mild bilateral paresthesia, mild flaccid quadriparesis, and reduced grip strength bilaterally. The patient was given three mL Albuterol-ipratropium via nebulizer but continued to develop worsening tachypnea. The patient wasupgraded to the Intensive Care Unit (ICU) due to concern for impending respiratory failure, and successfully intubated and started on volume-controlled ventilation. An arterial line was placed post-intubation and arterial blood gas demonstrated respiratory alkalosis (pH 7.49, pCO2 29,HCO3 22). The patient’s complete blood count (CBC), comprehensive metabolic panel (CMB), and Magnesium did not demonstrate any significant abnormalities. Coagulation studies recorded an elevated D-dimer of 1050 ng/mL. Lower extremity venous ultrasound and CT angiogram ruled out deep vein thrombosis and pulmonary embolism respectively. A blood sample was sent to the center for disease control (CDC) for analysis of Clostridium Botulism (C. Botulism) toxin A/B/E/F. The CDC did not initially recommend anti-toxin administration, and neurology was consulted to rule out other neuromuscular causes. Day two, the patient remained quadriparetic with poor inspiratory effort on ventilator. Without improvement, the CDC recommended antitoxin administration. Six hours post administration the patient underwent a spontaneous breathing trial, was successfully extubated, and placed on continuous positive airway pressure (CPAP). Day three, the patient moved from CPAP to nasal cannula. Physical therapy began working with her due to minor paraparesis and ataxia, improving dysphagia, and diplopia.?The patient was discharged on day four with primary care follow up. Discussion In accordance with the CDC there has been a rise in the number of botulism poisoning cases in the United States. Botulism is a life threatening neuroparalytic syndrome from a toxin released by C. Botulism. The toxin can spread around the injection site and through blood and nerves. The use of OnabotA has increased recently, but there is no evidence yet to claim that there is a causation. The patient did not include the Botox injections in her initial history, potentially reducing her length of stay on ventilator with knowledge of the differential. Physicians must have heightened suspicion as early detection, therapy and antitoxin administration can reduce respiratory flair.