The European Center for Disease Control and Prevention (ECDC) announced on Tuesday that the Turkish authorities have closed the services of two hospitals involved in the botulism outbreak and have opened investigations to clarify what happened.
Through a statement, the ECDC has raised to 67 cases of botulism (53 in Turkey, 12 in Germany, one in Austria and one in Switzerland) in Turkey. All patients underwent medical interventions between February 22 and March 1 aimed at helping them lose weight with gastric injections of botulinum toxin.
Of the 63 cases with available information, 60 are related to a private hospital in Istanbul and three to a private hospital in the Turkish city of Izmir. In these two centers, “the activities of the relevant departments of both hospitals have been suspended and investigations have been opened against the parties involved.”
The European organization details that the investigations carried out by the Turkish authorities have revealed that “authorized” botulinum toxin products were administered in the treatments, but that these products “are not approved for the treatment of obesity by intragastric injection.”
On the reasons behind these cases, the ECDC points out that “at this time it is not clear if this event represents a therapeutic or procedural problem in the hospitals involved, or if there is a problem with the product administered.”
At the moment, there are mild and severe cases, although there have already been several hospitalizations and admissions to Intensive Care Units (ICU). Those hospitalized have received treatment with botulinum antitoxin.
Intragastric botulinum toxin injection in animals and humans is sometimes used as a treatment for obesity, although it is not authorized in Spain. Its effect would include the delay of gastric emptying and the induction of early satiety, with the consequent decrease in intake and weight loss. However, it is more risky than other weight loss operations, as this toxin in high doses is dangerous.
Given this risk, the ECDC has “strongly” asked citizens to avoid intragastric treatments with botulinum toxin against obesity in Turkey, since “they are currently associated with a significant risk of developing botulism.”
In the case of the European patients, they are all middle-aged adults and ten of them (eight from Germany and those affected in Austria and Switzerland) received treatment at the same clinic.
According to the information currently being handled by the European body, for the moment there are no indications that the treatment was organized by a commercial medical travel company. Instead, information received from patient interviews indicates that a ‘WhatsApp group’ was used to contact the hospital.
Three of the cases in Germany recall the name of the product used in their operations, and in all of them it matched. The case of Austria is a woman between the ages of 25 and 44 who received this treatment on February 22. According to this patient, her injection was “self-administered” at the clinic itself. The woman was hospitalized with symptoms of botulism (ptosis, dysphagia, dyspnea, neck weakness, generalized muscle weakness).
Meanwhile, the Swiss case remains suspicious and is not yet confirmed. She is also a woman, in this case between 45 and 64 years old, who also received the injection on February 22 at the suspected clinic.
European authorities fear that more cases will come to light, “taking into account the possible variation in the clinical presentation of botulinum disease.” “New cases may occur, especially among people traveling to Turkey to undergo medical treatment involving intragastric injection of botulinum neurotoxin,” they note.
The ECDC advises people who have traveled to Istanbul and Izmir to undergo this treatment and present symptoms compatible with botulism (weakness, difficulty breathing and/or swallowing) to see a doctor “as soon as possible”.
This is not the first time that the ECDC has investigated similar cases of botulism. In 2019, France reported a suspected case of botulism in a 25-44-year-old woman after an intragastric injection of botulinum neurotoxin in Egypt for weight loss. Later, she had to be hospitalized upon her return to France.
In addition, a World Health Organization (WHO) alert on medical products from August 2022 reported five counterfeit batches of botulinum neurotoxin in five countries: Jordan (May 2022), Turkey (May 2022), Kuwait (June 2022), 2022), UK (June 2022) and Poland (July 2022). However, ECDC “does not know if these batches have been used for treatment in the cases reported so far.”
Outbreaks of iatrogenic botulism, sometimes related to counterfeit or unauthorized botulinum neurotoxin, have also been reported in the past following different clinical procedures, for example in Egypt and Turkey.
Botulism is a serious neuroparalytic disease caused mainly by botulinum toxin, a product of the ‘Clostridium botulinum’ bacterium. The disease occurs naturally in four different forms: foodborne, intestinal, infant, and wound botulism.
There are two other forms of botulism that do not occur naturally: inhalation and iatrogenic, which is the newer form of man-made botulism, mostly in medical treatments with few guarantees. Thus, poisoning can occur as an adverse event after the administration of botulinum neurotoxin for therapeutic or cosmetic reasons.
Although considered rare, people receiving botulinum neurotoxin injections for cosmetic purposes (for example, for facial wrinkles) or therapeutic treatments (for example, for the treatment of muscle spasticity) may develop iatrogenic botulism if injected with a excessive dose.
The symptoms of iatrogenic botulism are characterized by weakness and difficulty swallowing. Toxicities after cosmetic treatment include ophthalmologic and oropharyngeal symptoms (blurred vision, drooping eyelid, difficulty swallowing, and dry mouth), while toxicities after therapeutic treatment are related to shortness of breath and weakness.
The symptoms of botulism can be very severe and require intensive care treatment, as well as administration of an antitoxin. Even when these treatments are available, full recovery often takes weeks or months, as the ECDC recalls. In the case of foodborne botulism, between 5 and 10 percent of cases are fatal.
