Many times when one looks back, it is easy to say "it seemedlike a good idea at the time." After all, Botox (botulinum toxintype A), has been shown to help erase skin wrinkles. The resultshave been great. So when a friend offers to get some of it foryou, perhaps at much less cost, and even inject it for you,well, that seems like a deal that’s too good to be true.Sometimes it is.
Caveat emptor in Latin means "let the buyer beware." This mightbe a good subtitle of the article by Dr. Souayah and coauthorsin this issue of Neurology (Souayah N, Karim H, Kamin SS, McArdleJ, Marcus S. Severe botulism after focal injection of botulinumtoxin. Neurology 2006;67:1855–1856). The article tellswhat happens when someone was treated with an inappropriatepreparation of botulinum toxin, apparently by a friend. Theresults were disastrous.
A 34-year-old woman received botulinum toxin injections forcosmetic purposes. However, the preparation was not the FDA-approvedbotulinum toxin type A (brand name Botox). The injected substancewas apparently research-grade toxin and was bought on the Internet.Two days after the injection, the woman developed progressiveshortness of breath, swallowing difficulties, double vision,and generalized weakness. By the time she was examined by aneurologist, she was totally paralyzed with the exception ofa little movement of her left big toe. An attempt to limit theparalysis with serum against the toxin was too late and didnot help.
Electrical studies of various arm and leg muscles showed themto be totally inactive. Tests showed that the woman had extremelyhigh levels of botulinum toxin in her blood. In fact, the authorsof the article estimate that she had been given over 2,000 to5,000 times the usual amount given for cosmetic purposes!
Botulinum toxin works by interrupting the connections betweennerves and muscles. Recovery occurs only when more of the proteinthat has been inactivated by the toxin is made (see About Botulism).The patient was treated in the intensive care unit for any developingproblems while waiting for recovery, which was slow. By 3 weeks,she could only shrug her shoulders and move her eyes. By 5 weeks,she could answer with a yes or no. The last time she was evaluated,10 months after she was hospitalized, she still had problemswith muscle pain and weakness and had some shortness of breath.
Apparently, a second person also received injections at thesame time. The authors do not give information about the secondperson, but hopefully he/she recovered as well as the persondescribed in the article. Although having continued problemswith muscle pain and weakness does not sound like a "good" recovery,it must be remembered that botulism has claimed many lives overthe last hundred years. Even now, deaths occur.
Botulinum toxin is one of the most poisonous substances known.But when that same toxin is carefully isolated and purified,it can be used as a powerful and effective medication.
Botulinum toxin was first introduced as a clinical tool in the1980s, and its use has skyrocketed as doctors have applied itto an increasing number of medical conditions. It has revolutionizedthe treatment of a condition called dystonia. This movementdisorder causes involuntary contractions of muscles acting inopposite directions, which results in odd postures and twisting,writhing movements of the neck, trunk, hands, or legs. Withperiodic injections of botulinum toxin into the muscles mostaffected, countless patients have been relieved of their symptoms.
Perhaps there is a general misunderstanding that anything thatcan be used for cosmetic purposes must be easy to use and safe.But just like cosmetic surgery, professional training is a must.
All medications have potential side effects. However, patientsneed to be aware that when appropriately used by trained doctors,botulinum toxin has a remarkable safety record. The importantpoint is that it should be administered only by someone withconsiderable experience with the medication. It also must beemphasized that the botulinum toxin used in this sad case wasNOT the commercial product found in pharmacies and administeredby doctors. This was a research-grade product never meant formedical use in humans. And that is another lesson to be learnedfrom this story, one that has a parallel in a warning of innumerablemothers to innumerable children. Don’t take candy fromstrangers, and don’t use a medication unless you knowwhere it came from!
Botulism is a poisoning from one of the most powerful toxinsknown. It is produced by a family of bacteria, the Clostridia.This poison, called botulinum toxin, is a protein that interfereswith the normal flow of signals from certain nerves to musclesand glands. If enough toxin is present, it can cause a seriousor even fatal illness.
The spores of Clostridia bacteria are found in the soil, andthe bacteria grow in many places. However, it is in conditionswhere there is little oxygen that they multiply rapidly andare most likely to be harmful to people. There are three commonways to get botulism:
Food-borne botulism occurs by ingesting the toxin itself byeating foods that have not been properly sterilized.
Infantbotulism occurs by eating the bacteria or spores.
Wound botulismoccurs by infection of cuts and wounds by contaminatedsoil.
There are somewhat over 100 cases of botulism reported eachyear in the United States. The largest number of these casesis reported in infants. Infant botulism results from eatingbacteria or spores, which then grow in the gastrointestinaltract. After multiplying in the gut, the poison is producedand then absorbed. This mostly occurs in infants less than 6months old who do not yet have the usual bacteria in their intestines.About a quarter of all cases are adult food-borne. These occurmostly after people eat improperly sterilized or contaminatedhome-preserved food, although any source can be contaminated.So people who eat improperly prepared foods are at risk. Thesmall number of remaining cases of botulism is from infectedwounds, since the bacteria live in the soil.
Botulinum toxin is taken in by certain nerve cells (neurons).The particular neurons that take up the toxin are those thatuse a specific neurotransmitter, called acetylcholine. (Neurotransmittersare substances that help messages pass between neurons and theirtargets, such as a muscle or gland.) These neurons control musclemovements and certain secreting glands, such as saliva and tears.Therefore, the symptoms of poisoning are dry eyes, dry mouth,and muscle weakness (see below). The muscle weakness includesthe face, limbs, and even the digestive tract, leading to constipation.Double vision and difficulty speaking and swallowing are common.Weakness of the diaphragm and rib muscles leads to difficultybreathing, and sometimes patients need to be put on a respirator.Infant botulism is usually suspected when young infants developconstipation, poor feeding, and floppy heads.
Destroying the spores requires moist heat of 120 °C (220°F) for 30 minutes. However, the toxin can be easily inactivatedby boiling for 10 minutes or heating to 80 °C (180 °F)for 30 minutes. If you enjoy home canning, make sure to usethe proper methods for sterilizing and sealing. Do not eat cannedor bottled food where the seal has been broken. Acidic foods(such as tomatoes) and acidic conditions seem to make it moredifficult for the spores to become active bacteria.
A specific antiserum is available to counteract the toxin. However,this must be used before the toxin enters the neuron. Whateveramount enters the neuron will not be able to be "neutralized"by the antiserum, and some weakness will develop. Patients mustgo immediately to a hospital, since difficulty breathing candevelop rapidly. When such breathing difficulties are severe,patients need to go on a respirator. Luckily, the toxin is eventuallydestroyed by the body, and with intensive care, most patientscan make a full recovery.
When the toxin is carefully purified, it can be used as a powerfulmedical tool. By taking advantage of the fact that the toxinlessens muscle activity, we can use it to treat a number ofmedical conditions where muscle overactivity is a problem. Thedoctor must be careful with the amount used and where it isplaced (it is given by injection with a needle rather than takenby mouth). However, manufactured product is carefully measuredin each vial and when used correctly has a very good safetyrecord.
Botulinum toxin under the brand Botox has received approvalfrom the Food and Drug Administration for cosmetic (nonmedical)uses as well. The major use is in treating wrinkles and faciallines that result from overactive pulling of the small musclesunder the skin. It has proven to be an additional choice tothe traditional "face lift."
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What is botulism?
What causes botulism?
