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If it enters the bloodstream, it can cause botulism presenting with a typical pattern of motor and autonomic dysfunction. An international expert panel organised by IAB\u2014Interdisciplinary Working Group for Movement Disorders explored iatrogenic botulism after BT's medical use (IB), reached conclusions and formulated recommendations. When injected into its target tissue, BT binds to gangliosides on cholinergic nerve terminals before it is internalised permanently. Small amounts of BT, however, are circulating within the bloodstream. When BT type B is applied, IB-B occurs frequently, typically affecting the autonomic nervous system. When BT type A is applied, IB-A only occurs in special circumstances, even when high doses are used. We identified 236 patients with IB-A in the literature. All IB-A was mild or moderate and fully reversible. In 212 patients, it occurred with unapproved BT use. In 116 of them, unapproved BT preparations were used, in 81, unapproved indications were treated and in 15, underlying neuromuscular impairment including myasthenia gravis, Lambert-Eaton myasthenic syndrome, amyotrophic lateral sclerosis and spinal muscle atrophy were contraindications for BT use. In 24 patients, IB-A occurred in approved BT use. Their evaluation was frequently incomplete, so that causes for IB-A often remain unclear. They may include presence of differential diagnosis, subclinical neuromuscular impairment and interference with additional diseases. When IB is suspected, proper evaluation is necessary to verify it and to identify its causes. Off-label use is common in BT therapy. However, it should be performed with caution, especially in children and when high doses are applied. High BT doses should not be applied to low volumes of target tissues, in order not to exceed the BT binding capacity.<\/jats:p>","DOI":"10.1007\/s00702-025-03083-y","type":"journal-article","created":{"date-parts":[[2026,1,31]],"date-time":"2026-01-31T08:14:45Z","timestamp":1769847285000},"page":"949-957","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Iatrogenic botulism: a risk for botulinum toxin's medical use?"],"prefix":"10.1007","volume":"133","author":[{"given":"Dirk","family":"Dressler","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"J\u00fcrgen","family":"Frevert","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eric A.","family":"Johnson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Klaus","family":"Fink","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sabine","family":"Pellett","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sanjay","family":"Pandey","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Uwe","family":"Walter","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pawel","family":"Tacik","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Petr","family":"Kanovsky","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gholam Ali","family":"Shahidi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Norbert","family":"Br\u00fcggemann","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Raymond L.","family":"Rosales","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maja","family":"Relja","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lingjing","family":"Jin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jose Alberto Sagastequi","family":"Rodriguez","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lizhen","family":"Pan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gerard E.","family":"Francisco","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Huifang","family":"Shang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xue","family":"Bai","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fereshte","family":"Adib Saberi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,1,31]]},"reference":[{"key":"3083_CR1","doi-asserted-by":"publisher","DOI":"10.1097\/MD.0000000000010659","volume":"97","author":"L Bai","year":"2018","unstructured":"Bai L, Peng X, Liu Y, Sun Y, Wang X, Wang X, Lin G, Zhang P, Wan K, Qiu Z (2018) Clinical analysis of 86 botulism cases caused by cosmetic injection of botulinum toxin (BoNT). 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He is shareholder of Allergan and holds patents on botulinum toxin and botulinum toxin therapy. He provides professional consulting services to pharmaceutical companies and professional investment institutions on all aspects of botulinum toxin drugs. He is co-founder and member of the board of directors of Wisper Bio and founder of The Wittgenstein Organisation. J\u00fcrgen Frevert acts as a consultant for Merz Aesthetics. Eric A Johnson is a retired Professor, University of Wisconsin, Madison. He has conducted research on botulinum toxins for more than 40 years. EAJ has started four businesses in the botulinum toxin field. He holds more than 30 patents in the areas of botulinum toxin and food safety. Uwe Walter has received speaker honoraria and travel grants from Bristol-Myers Squibb, Canon Medical Systems Europe B.V., Ipsen Pharma, Merz Therapeutics, and an unrestricted research grant from Merz Therapeutics outside the present study. He was funded by the German Federal Ministry of Education and Research (BMBF) outside the present study. He serves as Joint Editor-in-Chief of the European Journal of Ultrasound (Thieme, Stuttgart, Germany). Pawel Tacik received honoraria for services provided to Abbott, AbbVie, Boston Scientific, Desitin, Ipsen, Medtronic and Merz. Petr Kanovsky has received speaking honoraria and academic research grant from Ipsen and speaking honoraria from Merz. Raymond L Rosales has received travel grants and lecture fees from Ipsen and AbbVie. Maja Relja has nothing to disclose. Jose Alberto Sagastequi Rodriguez has received fees from Ipsen, Allergan and Merz as a lecturer in symposia and training courses. He has received invitations for. Alberto Sagastequi Rodriguez has received fees from Ipsen, Allergan and Merz as lecturer in symposia and training courses. He has been invited to conferences and  Gerard Francisco AbbVie: research and consulting. Ipsen: research and consulting. Lifeward: consulting. Merz: research and consulting. Ottobock: research. Revance Therapeutics: research. Saol Therapeutics: research and consulting.  Fereshte Adib Saberi is founder and owner of IAB - Interdisciplinary Working Group for Movement Disorders. She received reimbursement from Abbot, AbbVie, Almirall, Allergan, Bayer, Desitin, Dynamed, Hempel GesundheitsPartner, Ipsen, Johnson & Johnson, Licher, Meda, Medtronic, Merz, Orion, PTZ Nawrath, Sensomotorik & Rehabilitation Hellmuth & Thiel, Sintetica, Sporlastic, Sun, Teva, Tricumed, TRS Med, UCB. Klaus Fink, Sabine Pellet, Sanjay Pandey, Gholam Ali Shahidi,  Norbert Br\u00fcggemann, Lingjing Jin, Lizhen Pan, Huifang Shang,  and Xue Bai has nothing to declare.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of interest"}}]}}