August 28, 2013 E-Pearl: Weakness Without Wrinkles: latrogenic botulism

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August 28, 2013

Botulinum is a potent neurotoxin with increasing indications in the treatment of a wide array of neurologic disorders including blepharospasm, cervical dystonia, hemifacial spasm, spasticity and others. While clinical benefit results from local action against presynaptic neurotransmitter release primarily at the neuromuscular junction, systemic effects are known to occur. Rarely, patients can develop systemic weakness, ptosis, dysarthria, dysphagia, and head drop typically beginning approximately 7-14 days after local therapy (1). Prompt recognition, electrodiagnostic confirmation, and exclusion of alternative causative etiology such as underlying myasthenia gravis or junctional disorder imperative (2).


  1. Coban A, Matur Z, Hanagasi HA, Parman Y. Iatrogenic botulism after botulinum toxin type A injections. Clin Neuropharmacol 2010; 33: 158-160.
  2. Bhatia KP, Munchau A, Thompson PD, Houser M, Chauhan VS, Hutchinson M, Shapira AH, Marsden CD. Generalised muscular weakness after botulinum toxin injections for dystonia: a report of three cases. J Neurol Neurosurg Psychiatry 1999; 67: 90-93.   

Submitted by Roy Strowd, M.D. Resident Physician, Wake Forest School of Medicine, Winston Salem, NC.

Dr. Strowd is a member of the Resident and Fellow Section of Neurology.

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