In a rare case, botulinum toxin injections in large doses can precipitate or worsen myasthenia gravis. Such symptoms include weakness, ptosis and difficulty chewing.
Botulinum toxin injections also can cause periorbital complications such as pseudoherniation of the infraorbital fat pads, lagophthalmos, and dry eyes. Fortunately, these complications can be avoided by injecting smaller amounts into the upper eyelid and using the correct technique.
Symptoms
Botulinum toxin type A (BoNT/A) has been reported to produce a clinical picture mimicking MG in a small number of patients. Most of these cases were reported in children with hemifacial spasm, blepharospasm, and cervical dystonia; others included bruxism and focal dystonia.
Injectable neurotoxin types A and B, a class of medications called botulinum toxin, block nerve signals that cause uncontrollable muscle tightening. This medication can help control many movement disorders, including hemifacial spasm and blepharospasm, but it does not cure these problems.
The most common side effects of botulinum toxin injections are drooping eyelids (ptosis) and itching, swelling, or bruising of the eyes. These symptoms may occur in some people and can last for a few days or more after treatment, but usually go away within a few weeks.
Other side effects include slurred speech, trouble swallowing, weakness of the arms and legs, difficulty breathing, or a change in voice or a hoarseness. If these effects are severe, they may require medical attention.
If you experience any of these symptoms, tell your doctor immediately. They may need to do an electrodiagnostic test to find out if you have MG or another neuromuscular disorder.
Your doctor may also want to test your reflexes and muscles. These tests can help your doctor diagnose Myasthenia Gravis and give you the best treatment.
You will need to have several injections to control your condition. These injections will be done by a doctor who is trained in these procedures. It is important that the doctor is able to do these injections correctly and safely.
Before receiving your first injection, be sure to tell your doctor about any other treatments you are taking. They may need to adjust the dose or schedule of your medication to avoid side effects.
Your doctor will also need to know if you have any other conditions or health problems, such as glaucoma, heart disease, diabetes, seizures, or a history of bleeding problems. You should also tell your doctor if you have had any surgery or have been treated with a medication that can affect blood clotting, such as heparin.
Diagnosis
The use of Botox (Clostridium botulinum toxin type A) for various indications is on the rise in neurology and dermatology. Its injection can disturb communication between nerves and muscle cells, and cause alterations similar to those seen in neuromuscular disorders such as myasthenia gravis.
In this case report, two patients referred for neurophysiological evaluation of suspected myasthenia gravis (MG) were found to have had transient side effects such as weakness all over the body and double or blurred vision that were linked to Botox use. Their symptom onset was a few days after participation in a “botox party” where the patient had received bilateral Botox injections to the orbicularis oculi and glabellar muscles by a nurse at a beauty clinic.
This is a relatively new problem and only a small number of people have reported symptoms of Myasthenia Gravis after botulinum toxin type A injection. The most common symptoms of Myasthenia Gravis that are reported after botulinum toxin type a injection are muscle weakness, drooping eyelids, and blurred vision.
If you experience these symptoms after an onabotulinumtoxinA injection, call your doctor or get emergency medical help right away. These symptoms may include loss of strength all over the body; difficulty breathing or swallowing; drooping eyelids or brow; hoarseness; changes in voice; and inability to control urination.
When botulinum toxin is injected into muscles, it causes muscle paralysis by blocking the release of acetylcholine at the nerve-muscle junction, which decreases the ability of the brain to tell the muscles to contract. It is used to treat a number of conditions, including strabismus (crossing of eyes), cervical dystonia (disorder that causes stiffness and tightening of the neck), blepharospasm (shrinkage or contraction of the upper eyelids), spasticity, urinary incontinence, overactive bladder, and chronic migraines.
Botulinum toxin is also used to treat severe underarm sweating. When injected into the muscles of the armpits, it blocks the signals to the sweat glands that cause them to overreact and produce excessive amounts of sweat.
OnabotulinumtoxinA is a prescription medication that comes as a powder to be mixed with a liquid and injected into muscles, the skin, or into the wall of the bladder by your doctor. Your doctor will choose the best place to inject onabotulinumtoxinA and will administer it slowly into your muscle or through the wall of your bladder. Your doctor may also need to perform an exam of your underarms, arms, and legs to find the areas that need treatment.
Treatment
Treatment with Botulinum Toxin Type A (BoNT/A) is the only therapy that has been proven to be effective in the treatment of Myasthenia Gravis. It is a neurotoxin produced by Clostridium botulinum that causes paralysis by presynaptically binding to cholinergic nerve terminals at the neuromuscular junction and decreasing the release of acetylcholine. This is a highly effective treatment for Myasthenia Gravis and other movement disorders such as dystonia and spasticity [2,3].
When used properly, BoNT/A injections are very safe. However, there are a few side effects associated with this drug, including pain, edema, erythema, ecchymosis and short-term hypesthesia. These side effects can be avoided by using the correct needle size, avoiding the use of topical anesthetic creams and by using a preservative-enhanced saline solution to dilute the botulinum toxin.
Medications that may interact with Botox include anticonvulsants (i.e., phenytoin, valproic acid, carbamazepine), antibiotics, anticholinergic medications, sedatives, and alcohol. These medications can change the final effect of the injection and trigger unexpected complications, particularly with large doses.
For example, large doses of aminoglycosides and cyclosporine can prevent the release of acetylcholine into the neuromuscular junction, resulting in a clinical state that mimics botulism. Therefore, discontinuing these medications or reducing their doses can avoid this complication.
Another complication that can occur after BoNT/A injection is difficulty in opening the mouth, which is due to paralysis of the lateral pterygoid muscles. This can be treated by mechanotherapy.
A few rare cosmetic complications have also been reported following botulinum toxin injection, such as asymmetry in facial expressions and an expressionless mask-like face. These complications usually are the result of different layers of the same muscle responding differently to Botox.
The most common adverse reaction after botulinum toxin injection is localized pain. This is most likely related to the needle puncturing the skin, but can also be the result of the use of a preservative-enhanced solution that increases the pH of the saline. Other side effects include dry skin and flakiness after the injection, which may be temporary or permanent, depending on the patient’s individual sensitivity to the toxin.
Recovery
Myasthenia Gravis is a progressive neuromuscular disease that results in muscle weakness or paralysis. The condition is caused by the inability of the muscles to contract or relax due to an excess of acetylcholine (ACh) released by nerves. Injections of Botulinum Toxin Type A can be helpful in treating this condition.
Botulinum Toxin is a potent and poorly immunogenic drug produced by the gram-positive spore-forming rod Clostridium botulinum in plants, soil, water and animals. It inhibits the release of ACh from skeletal and autonomic cholinergic nerves. The injection of this drug is a very effective treatment for many disorders.
Injections of Botulinum Toxin may cause severe side effects if they are injected into the wrong muscle group or in the incorrect location. To prevent these complications, a qualified practitioner should always follow correct injection techniques. For example, it is essential to keep all injections outside the “orbital zone,” defined by the infraorbital ridge and a point 1 cm lateral to the lateral canthus.
Generalized diffusion of Botulinum Toxin is another major cause of severe side effects. This occurs when the muscle fibers that were injected with the toxin do not respond as expected and instead begin to spread in the surrounding muscles. This is most common with injections into the rectus muscles but can also occur in other areas, especially when injections are performed with a very high dose or in a large area.
Another common botulinum toxin reaction is hypersensitivity, a reaction that occurs when the body becomes allergic to the botulinum toxin. This reaction is most likely to occur with the use of a high-dose or in a large area and should be treated with epinephrine.
The most serious botulinum toxin reaction is a life-threatening occurrence known as botulism. This happens when the body produces botulinum toxin antibodies that interfere with the function of botulinum toxin. It can result in a variety of symptoms including weakness, difficulty speaking and swallowing, blurred vision, diplopia, or respiratory arrest.
The majority of these side effects can be controlled by using lower doses of the toxin. However, they can recur if the dosage is too high or if the injection is not done properly by a qualified physician.
