Acta Scientific Paediatrics (ISSN: 2581-883X)

Case Report Volume 5 Issue 4

Botulinum Toxin A (Btx-A) Injection: A Rare and Complicated Pediatric Case from Kurdistan, Iraq

Nizar Bakir Yahya1, Hevan Adel Al-Atroushy2, Stefano Maiandi3 and Federica Buzzi4*

1MBChB, FIBMS and Assistant Professor, College of Medicine, Department of Pediatric, University of Duhok, Duhok, Iraq
2Pediatrician FIBMS, Pediatric Intensive Care Unit, Hevi Pediatric Teaching Hospital Duhok, KR, Iraq
3MsN, Professional Development and Research, Directorate of Health Professions, ASST of Lodi
4RN, Head of pediatric and neonatal intensive care clinical training, E.U. Project MADAD, Italian Association for Solidarity among Peoples, Duhok, KR, Iraq Nurse, Hematology and Bone Marrow Transplantation Unit and Pediatric Immunohematology Unit, IRCCS San Raffaele Scientific Institute, Milan

*Corresponding Author: Federica Buzzi, RN, Head of pediatric and neonatal intensive care clinical training, E.U. Project MADAD, Italian Association for Solidarity among Peoples, Duhok, KR, Iraq.

Received: December 13, 2021; Published: March 25, 2022


Botulinum neurotoxin is the most potent poison known to humans. The active form of the Clostridium botulinum spore produces a neurotoxin that causes paralysis. Many botulism presentations are subtle and difficult to diagnose. However, botulinum can also have therapeutic uses, and the indications are different, including the reduction of muscle spasticity in pediatric patients. The therapeutic use of botulinum toxin can cause several complications, including the possibility of developing botulism.

Treatment of botulism consists of administration of antitoxins, hospitalization, close monitoring, and respiratory support as needed. The mortality rate of patients who develop botulism has dramatically decreased in developing countries but not in low-middle income countries because resources are severely limited. We report the first case of botulism after botulinum injection in a patient with hypoxic ischemic encephalopathy. The diagnosis was very complicated and late given the scarce resources present in Kurdistan, Iraq. The patient required advanced and long-lasting care.

The child was hospitalized for 92 days, 56 of which the patient was on mechanical ventilation. The patient was treated without any antidote as it was not present, and he had no further neurological sequelae following the event.

Keywords: Botulinum Toxin; Injection; Pediatric; Complicated


  1. Jankovic J and Brin MF. “Botulinum toxin: historical perspective and potential new indications”. Muscle Nerve Supply 6 (1997): S129-145.
  2. Jankovic J. “An update on new and unique uses of botulinum toxin in movement disorders”. Toxicon 147 (2018): 84-88.
  3. Anniballi F., et al. “New targets in the search for preventive and therapeutic agents for botulism”. Expert Review of Anti-infective Therapy 9 (2014): 1075-1086.
  4. Anniballi F., et al. “Foodborne botulism associated with home-preserved turnip tops in Italy”. Annali dell'Istituto Superiore di Sanità 1 (2015): 60-61.
  5. Wilkes J. “AAN Updates Guidelines on the Uses of Botulinum Neurotoxin”. American Family Physician 3 (2017): 198-199.
  6. Sobel J and Rao AK. “Making the Best of the Evidence: Toward National Clinical Guidelines for Botulism”. Clinical Infectious Diseases 1 (2017): S1-S3.
  7. Martin S-J., et al. “Wound botulism, its neurological manifestations, treatment and outcomes: A case series from the Glasgow outbreak, 2015”. Scottish Medical Journal 4 (2017): 136-141.
  8. Opila T., et al. “Trends in Outcomes and Hospitalization Charges of Infant Botulism in the United States: A Comparative Analysis Between Kids’ Inpatient Database and National Inpatient Sample”. Pediatric Neurology 67 (2017): 53-58.
  9. Griese SE., et al. “Pediatric Botulism and Use of Equine Botulinum Antitoxin in Children: A Systematic Review”. Clinical Infectious Diseases 1 (2017): S17-S29.
  10. Szuch E., et al. “Head drop after botox: Electrodiagnostic evaluation of iatrogenic botulinum toxicity”. Clinical Neurology and Neurosurgery 156 (2017): 1-3.
  11. Koman LA., et al. “Management of cerebral palsy with botulinum-A toxin: preliminary investigation”. Journal of Pediatric Orthopaedics 4 489-495.
  12. Novak I., et al. “State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy”. Current Neurology and Neuroscience Reports 2 (2020): 3.
  13. Strobl W., et al. “Best Clinical Practice in Botulinum Toxin Treatment for Children with Cerebral Palsy”. Toxins (Basel)5 (2015): 1629-1648.
  14. Nahm NJ., et al. “Management of hypertonia in cerebral palsy”. Current Opinion in Pediatrics 1 (2018): 57-64.
  15. Chatham-Stephens K., et al. “Clinical Features of Foodborne and Wound Botulism: A Systematic Review of the Literature, 1932-2015”. Clinical Infectious Diseases 1 (2017): S11-S16.
  16. Murray DM., et al. “Early EEG Grade and Outcome at 5 Years After Mild Neonatal Hypoxic Ischemic Encephalopathy”. Pediatrics4 (2016).
  17. Jankovic J. “Botulinum toxin: State of the art”. Movement Disorders 8 (2017): 1131-1138.
  18. Fortunato F., et al. “Food-borne botulism in Apulia region, Italy: an expert witness testimony”. Ann Ig2 181-185.
  19. Kuehn B. “Wound Botulism Outbreak”. JAMA6 (2019): 538.
  20. Kumar R., et al. “The Botulinum Toxin as a Therapeutic Agent: Molecular Structure and Mechanism of Action in Motor and Sensory Systems”. Seminars in Neurology 1 (2016): 10-19.
  21. Ibatullin RA and Magjanov RV. “Case of iatrogenic botulism after botulinotherapy in clinical practice”. Terapevticheskii arkhiv 11 (2018): 102-104.
  22. Hollung SJ., et al. “Completeness and correctness of cerebral palsy diagnoses in two health registers: implications for estimating prevalence”. Developmental Medicine and Child Neurology 4 (20177): 402-406.
  23. Arnon SS., et al. “Human botulism immune globulin for the treatment of infant botulism”. The New England Journal of Medicine 5 (2006): 462-471.
  24. Yu PA., et al. “Safety and Improved Clinical Outcomes in Patients Treated With New Equine-Derived Heptavalent Botulinum Antitoxin”. Clinical Infectious Diseases 1 (2017): S57-S64.
  25. Richardson JS., et al. “Safety and Clinical Outcomes of an Equine-derived Heptavalent Botulinum Antitoxin Treatment for Confirmed or Suspected Botulism in the United States”. Clinical Infectious Diseases 9 (2020): 1950-1957.
  26. Toubiana J., et al. “Kawasaki-like multisystem inflammatory syndrome in children during the covid-19 pandemic in Paris, France: prospective observational study”. BMJ 369 (2020): m2094.
  27. Chalk CH., et al. “Medical treatment for botulism”. Cochrane Database of Systematic Reviews 4 (2019): CD008123.
  28. Carrillo-Marquez MA. “Botulism”. Pediatric Review5 (2016): 183-192.
  29. Boerner RM., et al. “Pyridostigmine for the Reversal of Severe Adverse Reactions to Botulinum Toxin in Children”. Journal of Pediatrics 194 (2018): 241-243.
  30. Pirazzini M and Rossetto O. “Challenges in searching for therapeutics against Botulinum Neurotoxins”. Expert Opinion on Drug Discovery 5 (2017): 497-510.
  31. Walsh K. “Case reports on dangerous infectious diseases: a review of patient consent”. BMJ Military Health 3 (2020): 179-180.


Citation: Federica Buzzi., et al. “Botulinum Toxin A (Btx-A) Injection: A Rare and Complicated Pediatric Case from Kurdistan, Iraq”. Acta Scientific Paediatrics 5.4 (2022): 15-18.


Copyright: © 2022 Federica Buzzi., et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Acceptance rate33%
Acceptance to publication20-30 days
Impact Factor1.197

Indexed In

News and Events

  • Certification for Review
    Acta Scientific certifies the Editors/reviewers for their review done towards the assigned articles of the respective journals.
  • Submission Timeline for Upcoming Issue
    The last date for submission of articles for regular Issues is April 30th, 2024.
  • Publication Certificate
    Authors will be issued a "Publication Certificate" as a mark of appreciation for publishing their work.
  • Best Article of the Issue
    The Editors will elect one Best Article after each issue release. The authors of this article will be provided with a certificate of "Best Article of the Issue"
  • Welcoming Article Submission
    Acta Scientific delightfully welcomes active researchers for submission of articles towards the upcoming issue of respective journals.

Contact US