Iatrogenic Botulism Following Cosmetic Botulinum Toxin Injection Presenting With Respiratory Distress: A Case Report

Botulinum toxin (BoNT) is extensively used across a wide range of therapeutic and cosmetic applications due to its efficacy in inhibiting neuromuscular transmission and its well-established safety profile. While adverse effects are typically localized and transient, systemic complications - particularly iatrogenic botulism - are rare but potentially life-threatening events. Iatrogenic botulism results from unintended systemic spread of the neurotoxin, which can occur even at doses commonly used for cosmetic purposes. We report a rare and severe case of iatrogenic botulism in a previously healthy 47-year-old male who developed progressive neurological symptoms following cosmetic BoNT injections to the glabellar region. Within days of the procedure, the patient experienced worsening bilateral ptosis, ophthalmoplegia, dysarthria, and dysphagia, which progressed to respiratory muscle involvement requiring mechanical ventilation in an intensive care setting. Neurophysiological studies demonstrated findings consistent with a presynaptic neuromuscular transmission defect. The case presented several diagnostic challenges, as the early clinical features mimicked other neuromuscular disorders such as myasthenia gravis or brainstem stroke. Despite this, prompt recognition based on clinical suspicion led to the timely administration of heptavalent botulinum antitoxin, which was followed by gradual neurological improvement. This case underscores the importance of early identification and management of systemic BoNT toxicity, even in the context of routine cosmetic use. It also highlights the critical need for clinician awareness, early referral to specialized care, and a high index of suspicion in patients presenting with acute cranial neuropathies following BoNT administration. This report aims to highlight the potential for severe systemic complications associated with BoNT use and to emphasize the importance of early antitoxin administration.