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CORRESPONDENCE COLUMN
Year : 2007  |  Volume : 52  |  Issue : 3  |  Page : 163-164
Botulism-like syndrome without cholinergic involvement: A case report and two recommendations to avoid it


Dr. Balmis 148, Col. Doctores, Deleg. Cuauhtemoc, CP 06726, México DF, Mexico

Correspondence Address:
Andres Tirado-Sanchez
Dr. Balmis 148, Col. Doctores, Deleg. Cuauhtemoc, CP 06726, México DF
Mexico
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.35355

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How to cite this article:
Tirado-Sanchez A, Ponce-Olivera RM. Botulism-like syndrome without cholinergic involvement: A case report and two recommendations to avoid it. Indian J Dermatol 2007;52:163-4

How to cite this URL:
Tirado-Sanchez A, Ponce-Olivera RM. Botulism-like syndrome without cholinergic involvement: A case report and two recommendations to avoid it. Indian J Dermatol [serial online] 2007 [cited 2019 Dec 12];52:163-4. Available from: http://www.e-ijd.org/text.asp?2007/52/3/163/35355


We report the case of an 18-year-old female patient with bilateral weakness in arms muscles without cholinergic impairment after she was treated with botulinum toxin (Botox™) for axillary hyperhidrosis. She was suffering from severe axillary hyperhidrosis since early childhood. The patient gave her informed consent and was treated with a total dose of 400 U of diluted botulinum toxin in the saline solution that was administrated intradermally. The affected area was delineated with a HSM skin skribe pen and divided into squares of approximately 2 × 2 cm [Figure - 1].

The injections were performed with 0.05 mL solution for each square, reaching a total amount of 200 U for each axillae. We did not use previous local anesthetic block.

Two weeks after the initial dose, she presented with severe weakness in arm movements. We inquired for cholinergic signs and the occurrence of such signs were denied by the patient. Further, we performed a neurophysiological study on arms muscles distant from the injection sites; the study did not find any muscle or neural disease; however, it found pathological jitters; we confirmed the occurrence of neuromuscular transmission failure.

The patient showed a significant improvement in strength at the first week after the initial symptoms and a complete recovery of the strength in the subsequent 2 weeks. Four months after the therapy and the relapse of sweating, we used half dose of botulinum toxin (total dosage: 200 U, 100 U per axillae) and we did not find any side effects; the patient obtained a similar efficacy as that obtained with the previous dose.

The data obtained from this case are consistent with mild, localized botulism-like syndrome related to botulinum toxin. We never observe before this side effect with the use of this dose in any patient as in specialized literature consulted. [1],[2],[3],[4],[5] There are few reports where the botulinum toxin dose applied is higher than the dose we used in the patient without relevant side effects.

Possibly, the numerous intradermal injections (total number: 25) could have favored easier tissue deposits with localized neuromuscular affection. The absence of cholinergic involvement is possibly because the botulinum toxin did not reach circulation and did not have hematogenic spread.

We suggest not to use numerous injection sites and high dose when botulinum toxin is used for the first treatment [Figure - 2]. Further studies about this side effect are required and careful measures must be taken when we use botulinum toxin in patients who do not have a previous history of botulinum toxin treatments.

 
   References Top

1.James R, Phillips D, Collin J. Durability of botulinum toxin injection for axillary hyperhidrosis. Br J Surg 2005;92:834-5.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Solish N, Benohanian A, Kowalski JW; Canadian Dermatology Study Group on Health-Related Quality of Life in Primary Axillary Hyperhidrosis. Prospective open-label study of botulinum toxin type A in patients with axillary hyperhidrosis: Effects on functional impairment and quality of life. Dermatol Surg 2005;31:405-13.  Back to cited text no. 2  [PUBMED]    
3.Glaser DA. Treatment of axillary hyperhidrosis by chemodenervation of sweat glands using botulinum toxin type A. J Drugs Dermatol 2004;3:627-31.  Back to cited text no. 3  [PUBMED]    
4.Klein AW. Complications with the use of botulinum toxin. Dermatol Clin 2004;22:197-205.  Back to cited text no. 4  [PUBMED]    
5.Glogau RG. Treatment of hyperhidrosis with botulinum toxin. Dermatol Clin 2004;22:177-85.  Back to cited text no. 5  [PUBMED]    


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