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CASE REPORT article

Front. Pharmacol.

Sec. Respiratory Pharmacology

Volume 16 - 2025 | doi: 10.3389/fphar.2025.1680693

Botulism associated with cosmetic BoNT-A injections: respiratory failure and multidrug-resistant infection as emerging clinical challenges

Provisionally accepted
Yiming  SongYiming Song1Jinyu  LiJinyu Li1Yujiao  RenYujiao Ren2Wei  ZhangWei Zhang1Hongbo  LiuHongbo Liu3Zhenyi  LiZhenyi Li4Jiarui  XuJiarui Xu1Xingguo  ZhangXingguo Zhang1Dongxing  LiuDongxing Liu1*Yi  ZhouYi Zhou1*Baobao  FengBaobao Feng1*
  • 1Shandong Provincial Hospital, Jinan, China
  • 2Linyi People's Hospital, Linyi, China
  • 3Shandong Public Health Clinical Center, Jinan, China
  • 4Linyi Central Hospital, Linyi, China

The final, formatted version of the article will be published soon.

Botulism is a life-threatening neurotoxin-mediated disease characterized by flaccid descending paralysis which begins with cranial nerve palsies and might progress to extremity weakness and respiratory failure. Respiratory failure following cosmetic injections were scarcely reported due to the low dose of botulinum neurotoxin type A (BoNT-A) used. We present two cases of respiratory failure and multi-drug resistant (MDR) bacteria infection resulted from botulism following cosmetic injections. A 24-year-old female developed symptoms of dysphagia, blurred vision and dysarthria 6 days after cosmetic injections of BoNT-A, and progressed to respiratory failure which needed invasive mechanical ventilation 5 days later. Another 46-year-old female developed dizziness, headache and nausea 30 minutes after cosmetic injections of BoNT-A. Symptoms including ptosis, blurred vision, dysphagia, and slurred speech appeared one week later. The patient received mechanical ventilation due to the deteriorated respiratory failure. Both patients developed multi-drug resistant (MDR) bacteria infection during hospitalization. Though the pneumonia improved with effective antibiotics treatment, they underwent tracheostomy or second endotracheal intubation several days after successful weaning from the ventilator. Fortunately, they recovered without significant sequelae left. The widespread application of BoNT-A increases the risk of severe adverse events including respiratory failure and MDR bacteria infections. These two cases highlight the importance of pulmonary management for those with severe cosmetic botulism and health authorities' supervision on the cosmetic injections with BoNT-A in the future.

Keywords: respiratory failure, mechanical ventilation, Multi-drug resistant bacteria, Botulism, Botulinum neurotoxin type A

Received: 14 Aug 2025; Accepted: 03 Oct 2025.

Copyright: © 2025 Song, Li, Ren, Zhang, Liu, Li, Xu, Zhang, Liu, Zhou and Feng. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence:
Dongxing Liu, 15168888567@163.com
Yi Zhou, yizhou120@sina.com
Baobao Feng, robert_feng@163.com

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