Immediate Evaluation for Iatrogenic Botulism
This patient requires urgent evaluation for iatrogenic botulism, a rare but serious complication of botulinum toxin injection that can progress to life-threatening respiratory failure. The triad of weakness, dizziness, and vomiting occurring 3 days after Xeomin injection falls within the typical 5-30 day onset window for botulism and warrants immediate assessment 1, 2.
Critical First Steps
Immediately assess respiratory status and ability to swallow, as these are the most life-threatening complications of botulism 1. Specifically evaluate for:
- Shortness of breath or dyspnea (occurs in 65% of botulism cases) 2
- Difficulty swallowing or pooling of oral secretions (dysphagia occurs in 85% of cases) 2
- Upper airway compromise, which can occur before diaphragmatic involvement and cause respiratory failure 1, 2
Contact your local or state health department immediately to arrange emergency clinical consultation with CDC botulism experts, as this is required for diagnosis and potential antitoxin access 1, 3.
Perform Focused Neurologic Examination
Look specifically for the classic descending pattern of botulism 2, 3:
- Cranial nerve palsies: ptosis (81% of cases), diplopia (75%), blurred vision (80%), facial weakness, dysarthria (78%), voice changes (69%) 2
- Descending paralysis: weakness beginning in cranial nerves, then progressing to respiratory muscles, trunk, and extremities 3
- Preserved mental status: patients remain alert and oriented in 92% of cases despite appearing severely ill 2, 3
- Absence of fever: temperature should be <100.4°F; fever suggests alternative diagnosis or concurrent infection 2, 3
Distinguish from Alternative Diagnoses
The differential diagnosis includes conditions that can also cause weakness and vomiting 1:
- Gastroparesis: However, this would not explain acute weakness and typically presents with chronic symptoms 1, 4
- Myasthenia gravis: Distinguished by positive Tensilon test and different pattern of weakness 1, 3
- Guillain-Barré syndrome: Distinguished by elevated CSF protein and ascending (not descending) paralysis 1, 3
- Stroke: Ruled out by neuroimaging if focal deficits present 3
Assess Severity and Need for Hospitalization
Admit to hospital immediately if any of the following are present 1:
- Respiratory symptoms (shortness of breath, dyspnea, difficulty managing secretions)
- Difficulty swallowing
- Progressive cranial nerve palsies
- Any signs of respiratory compromise
Serial monitoring is essential as 87% of patients requiring intubation need it within the first 2 hospital days, and paralysis can progress rapidly 1.
Management Considerations
If iatrogenic botulism is confirmed or highly suspected 1:
- Supportive care is the cornerstone: With adequate critical care, including mechanical ventilation when needed, almost all patients survive and fully recover even without antitoxin 1
- Antitoxin may be considered: Contact CDC for availability, though benefit must be weighed against risks in iatrogenic cases 1
- Patients remain alert: Despite appearing severely ill, patients typically have intact cognition and require psychological support and clear communication 1
- Prolonged recovery expected: Hospitalization may last weeks to months with gradual recovery 1
Important Caveats
The 60-unit dose is well below the threshold for systemic toxicity in research studies (which showed safety up to 1,200 units) 5, making true iatrogenic botulism from this dose extremely unlikely. However, individual susceptibility varies, and the clinical presentation warrants thorough evaluation 5, 6.
Do not delay evaluation based on dose considerations alone—the clinical presentation takes precedence over theoretical risk calculations 1, 3.
Vomiting may represent gastroparesis or other gastrointestinal pathology rather than botulism, but this should not delay neurologic assessment given the concurrent weakness 1, 4.