A Retrospective Case Series Study of Illegal Cosmetic Iatrogenic Botulism: Outbreak Analysis and Response Lessons.

Background: Botulism is a rare and possibly life-threatening neuroparalytic syndrome. Recent large-scale outbreaks of iatrogenic botulism, primarily linked to cosmetic injections, have garnered significant attention.

Objectives: This study discusses the factors that may lead to the outbreak of cosmetic iatrogenic botulism (CIB), provides the epidemiological description of CIB cases and puts forward response measures.

Methods: All clinical data, laboratory investigations, and therapeutic procedures of CIB patients in a large single-center retrospective cohort (2014-2024) were reviewed and analyzed.

Results: Over a 10 year period, 161 cases of CIB were identified, of which 81 (50.31%) were hospitalized and 80 (49.69%) were outpatient cases. Most patients received botulinum toxin (BoNT) injections of unknown origin from unlicensed practitioners in non-medical settings. Severe and moderate cases of CIB accounted for up to 60%, with the majority of outbreaks occurring in 2024. The median time from botulism onset was 0 to 17 days, with the highest incidence occurring within 3 days following the injection. Hospitalized patients were discharged after a mean of 11.64 ± 9.40 days (range: 1 to 39 days), and symptoms resolved in botulism patients within a mean of 24.85 ± 11.67 days following treatment. Treatments included antitoxin administration, hyperbaric oxygen therapy, pyridostigmine, other symptomatic treatment and supportive care.

Conclusions: This represents the largest reported outbreak of illicit CIB worldwide, highlighting the risks associated with counterfeit BoNT, non-compliant practices, and underscoring the critical need for stringent surveillance of BoNT distribution. Clinicians should be adept at recognizing and adhering to the diagnosis, treatment, and follow-up management of CIB.