What is a danger from ordering "Botox" online?
October 18, 2024
MMWR recently published the results of their investigation of two outbreaks of botulism-one in Tennessee (TN) and one in New York city (NYC).1 Four patients presented to TN hospitals and three patients in NYC with ptosis, dry mouth, dysphagia, shortness of breath, and weakness. They had reported receiving botulinum injections in a nonmedical residential setting with a median of 3 days prior to presentation. The product used in TN was available and found to be counterfeit. The label reported a concentration of 150 units of botulinum toxin A, but it was likely an expired batch from 2017 of the 100 Units vial. The patients did not have any progression of disease after hospitalization. None of the 7 patients received the antitoxin as it only binds to “free” toxin that is circulating in the blood. The antitoxin cannot reverse disease as it does not bind to the toxin already taken up by the presynaptic terminals in the neuromuscular junction.
Botulinum neurotoxin binds to polysialogangliosides on the presynaptic membrane of cholinergic peripheral neurons. The neurotoxin is then internalized inside the neuron and cleaves the SNARE proteins that are needed for a vesicle containing acetylcholine to release its content.2 As a result, botulinum toxin stops release of acetylcholine into the synapse (“presynaptic blockade”). Antimuscarinic (dry mouth, constipation) and antinicotinic (weakness, paralysis) effects occur. The toxin does not cross the blood brain barrier, so the mental status of a poisoned patient remains intact until respiratory failure occurs.
The use of the product was thought to be for cosmetic purposes, but this report demonstrates the danger in non-licensed personnel administering a toxin in non-medical settings. Dose and source matters in a toxin as potent as botulinum.
References:
1. Illnesses After Administration of Presumed Counterfeit Botulinum Toxin in Nonmedical Settings — Tennessee and New York City, March 2024. MMWR:2024;73:609-11.
2. Botulinum neurotoxins. Toxicon 2013:67:31-36
Question prepared by: Saralyn R. Williams, MD, Professor of Emergency Medicine, Medicine, and Pediatrics