Iatrogenic botulism induced by cosmetic injection requiring mechanical ventilation: clinical characteristics and outcomes

Abstract

Introduction Cosmetic iatrogenic botulism is increasingly reported, but data on severe cases complicated by neuromuscular respiratory failure requiring mechanical ventilation remain limited. This study aims to characterize clinical features, treatment, and outcomes of such cases.Methods A retrospective analysis was performed on mechanically ventilated patients with severe iatrogenic botulism following cosmetic botulinum toxin injection from April 2024 to September 2025. Data on clinical characteristics, treatment and three-month outcomes were analyzed.Results Fifteen patients (14 females, mean age of 36.40 years) were included. The face was the most common injection site (12 cases, 80.00%), primarily for wrinkle reduction, calf reduction, and jawline contouring. Seven patients (46.67%) received unlicensed or unknown-brand botulinum neurotoxin, and six (40.00%) were injected in non-authorized institutions. All patients presented with ptosis, dysarthria, dysphagia, limb weakness, and abdominal distension. The duration of mechanical ventilation was 329.93 ± 162.81 hours. Seven patients (46.67%) underwent tracheotomy, and two (13.33%) required reintubation within 48 hours after extubation. The cumulative dose of botulinum antitoxin was 34.33 ± 13.32 × 104 international units, with one patient experiencing a mild allergic reaction that resolved with management. Mean intensive care unit stay duration was 28.53 ± 13.27 days. At the three-month follow-up, one patient reported residual facial paresis and dysphagia.Discussion Neuromuscular respiratory failure in severe iatrogenic botulism was associated with prolonged mechanical ventilation. The use of unlicensed products, injection in unauthorized institutions, and delayed medical care might contribute to severe systemic toxicity. The prolonged clinical course reflected the underlying mechanism of botulinum neurotoxin‑induced neuromuscular junction blockade and nerve terminal regeneration.Conclusion Among hospitalized patients with severe iatrogenic botulism, respiratory failure may necessitate prolonged mechanical ventilation, difficult weaning, and extended intensive care unit stay. Unlicensed products, non-authorized institution injection, excessive botulinum neurotoxin dosage, and delayed hospital presentation may be associated with disease progression.