Iatrogenic Botulism Following Cosmetic Botulinum Toxin Type A Injections: A Case Report from Saudi Arabia

Background: Botulinum toxin type A (BoNT-A) is widely used for cosmetic and therapeutic purposes and is generally considered safe when administered appropriately. However, systemic toxicity, including iatrogenic botulism, is a rare but potentially life-threatening complication. Case Presentation: A 28-year-old woman developed bilateral ptosis and diplopia one week after receiving cosmetic BoNT-A injections to the face, neck, and axillae at a private clinic. Her symptoms progressed to dysphagia, dysarthria, urinary incontinence, and proximal limb weakness. Neurological examination demonstrated bilateral ptosis, ophthalmoparesis, bulbar dysfunction, and symmetrical proximal weakness with preserved sensation. Routine laboratory investigations and brain imaging were unremarkable. Neurological assessment at the referral center supported the clinical diagnosis of iatrogenic botulism, with myasthenia gravis excluded. Heptavalent Botulinum Antitoxin (BAT), one single-use vial, was administered intravenously upon admission to the intensive care unit, approximately 5 days after symptom onset, followed by intensive supportive care and close respiratory monitoring. Public health authorities were notified, and an investigation of the administered product was initiated. The patient showed gradual neurological improvement and achieved complete functional recovery by day 48. Conclusion: Iatrogenic botulism should be considered in patients presenting with acute cranial nerve dysfunction and descending symmetrical weakness following BoNT-A injections. Early recognition, timely administration of antitoxin, and appropriate respiratory monitoring are essential for favorable outcomes.