Multnomah County Health Department has identified one suspect case of iatrogenic botulism following cosmetic injections of botulinum toxin. A case investigation is underway and local public health experts are coordinating to identify any further cases. Multnomah County released a press release today.
We request that area clinicians:
- Be aware of symptoms and signs of botulism (list below).
- Notify your Local Public Health Authority immediately of any suspected botulism (phone numbers below).
- Treat any suspected case of botulism as a medical emergency. Timely antitoxin administration is critical, must be coordinated through Public Health, and should not wait for test results.
- Testing for botulism must be approved by the Oregon Health Authority; specimens should be processed through your clinical laboratory and must be shipped directly to the CDC for resulting.
- Be aware of the market for counterfeit botulinum toxin products for cosmetic use, and for unofficial or self-administration of products purchased independently. Encourage your patients who are considering or seeking these procedures to receive services only from appropriately licensed clinicians and clinics.
Case reporting
Suspected botulism is immediately reportable in Oregon.
Local public health authorities may be reached 24 hours a day to report suspected botulism and/or positive test results for botulism.
- Clackamas County: 503-655-8411
- Clark County: 564-397-8182
- Multnomah County: 503-988-3406
- Washington County: 503-846-3594
- Oregon Health Authority: 971-673-1111 (for testing and antitoxin coordination)
Preferred testing for those with suspected botulism
The Oregon State Public Health Lab (OSPHL) does not test for botulinum toxin, so clinical laboratories will be directed to send specimens to CDC for testing with the required 50.34 form to avoid delay in submission. This is especially important for submitting stool specimens, as CDC will not test samples more than 72 hours after collection. Testing must be approved beforehand by an OHA Public Health Division medical epidemiologist.
All specimens must be kept refrigerated, not frozen. Use frozen cold packs during storage and transport. Specimens must be properly packaged using guidelines for shipping and packaging of Category B diagnostic specimens and CDC form 50.34.
Background
A Multnomah County resident was recently diagnosed with botulism. They have received botulism antitoxin and are recovering.
The person was known to have received injections of botulinum toxin product for cosmetic purposes prior to the onset of symptoms. In recent years, the CDC has investigated several cases of harmful reactions linked to counterfeit Botox or mishandled botulinum toxin injections.
This person received a botulinum toxin injection for cosmetic purposes on June 6 from a person found to be unlicensed to administer the injections and who administered the injections in a non-clinical setting. The person who administered the injections is a resident of Clark County, and Multnomah County is working with Clark County Public Health on an investigation.
Area clinics and healthcare providers may receive questions or requests for testing. Any individual suspected of having botulism symptoms should be evaluated urgently, as clinical deterioration may be rapid.
Although additional individuals with botulism may be identified, botulism is not infectious, and there is little risk to the general public at this time.
About botulism
Botulism is a symmetrical, descending flaccid paralysis caused by exposure to botulinum toxin, which binds irreversibly to presynaptic nerve endings, blocking the release of acetylcholine. Prompt administration of antitoxin can prevent any remaining unbound toxin from binding and thereby halt clinical progression.
Botulism can develop through exposure to the toxin, or to the C. botulinum spores with subsequent bacterial infection and in-situ formation of botulinum toxin in the body. The most common causes of botulism in adults in our area are consumption of contaminated food with preformed toxin, or through infection of wounds with Clostridium botulinum, as the spores are common in soil. Botulism may also be iatrogenic, inhalational, or intestinal—with intestinal botulism being most common in infants and individuals with gastrointestinal tract abnormalities. People with botulism are not infectious.
Iatrogenic botulism can occur in individuals receiving cosmetic injections, particularly of unlicensed products.
Botulism typically develops hours to days after exposure, depending on the intensity of exposure. In the United States, botulism has a 5–10% mortality rate with supportive care such as mechanical ventilation. The longer the interval between symptom onset and receipt of antitoxin the more persistent symptoms may be.
Botulism symptoms include dysphagia, diplopia, and dysarthria. Other characteristic symptoms may include blurred vision, ptosis (drooping eyelids), and weakness, progressing to a descending, symmetrical flaccid paralysis. Patients are usually mentally alert, and sensation remains intact. Neurologic symptoms may be preceded or accompanied by mild gastrointestinal disturbance such as constipation, vomiting, or diarrhea. The severity of symptoms and the rate of progression are highly variable, depending on dose and other factors. Respiratory distress may ensue if the muscles of breathing are compromised, and as such all patients require close monitoring of ventilatory status. In severe cases, patients may survive only after months on a ventilator.
Persons at highest risk for developing botulism in our area are those who are unhoused and may be eating discarded or unrefrigerated food, and people with injection drug use.
Botulinum antitoxin is available, and distribution is coordinated through the CDC and its U.S. Public Health Service Quarantine Stations. OHA Communicable Disease staff are available for consultation 24 hours a day at 971-673-1111.
Resources
Thank you for your partnership,
Richard Bruno, MD, MPH | Multnomah County Health Officer
Teresa Everson, MD, MPH, CPH | Multnomah County Deputy Health Officer
Christina Baumann, MD, MPH | Washington County Health Officer