A Hospitalist's Challenge: Systemic Botulism Following a Cosmetic Injection Requiring Antitoxin Therapy and Percutaneous Endoscopic Gastrostomy (PEG).

Botulinum toxin type A (BoNT-A) is widely used in cosmetic practice and generally considered safe, with adverse effects usually limited to transient local reactions. Rarely, systemic spread or counterfeit formulations can cause iatrogenic botulism, presenting with bulbar weakness and generalized neuromuscular dysfunction. We report the case of a 53-year-old woman who developed progressive dysphagia, bilateral ptosis, bifacial weakness, and proximal muscle weakness following cosmetic BoNT-A injections to the face and masseter muscles. Imaging and endoscopic evaluations were unremarkable, and myasthenia gravis (MG) was excluded. Despite initial partial improvement on pyridostigmine, her bulbar dysfunction worsened, necessitating administration of botulinum antitoxin and eventual percutaneous endoscopic gastrostomy (PEG) placement for nutritional support. Over subsequent weeks, she demonstrated gradual recovery, though mild ptosis persisted at discharge. This case underscores the potential for systemic botulism after cosmetic BoNT-A, particularly in the setting of unregulated or counterfeit products. Physicians must maintain a high index of suspicion in patients with recent cosmetic injections presenting with cranial or bulbar symptoms, as timely recognition and antitoxin therapy are essential to optimize outcomes and reduce morbidity.