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

Abstract 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 80 (49.69%) were hospitalized and 81 (50.31%) were outpatient cases. Most patients received botulinum toxin (BoNT) injections of unknown origin from unlicensed practitioners in nonmedical 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, 1-39 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, noncompliant 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. Level of Evidence: 4 (Therapeutic)