Botulinum toxin A
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Respiratory tract disorders, vomiting and hypoxia in a child: case report A 9-year-boy with spastic quadriplegic cerebral palsy developed vomiting, hypoxia and respiratory tract disorders including swallowing difficulties, stridor, pneumonia and airway obstruction during treatment with four botulinum toxin A injections for lower limb spasticity [time to reaction onset not clearly stated]; the injections were administered between July 2004 and December 2005 as a day procedure under short general anaesthetic. On each occasion, the boy received botulinum toxin A [Botox] 400 units diluted in 8mL of normal saline, divided between his calf muscles, adductors and hamstrings. Within hours of his first procedure, he developed stridor and increased breathing and, the next day, he developed vomiting and an NSAID-related episode of haematemesis. After airway positioning and receiving epinephrine [adrenaline] and dexamethasone, the boy’s symptoms improved. Overnight oximetry showed no significant nocturnal obstruction. He was discharged with ongoing stridor. At home, his respiratory symptoms persisted and, because of vomiting and swallowing difficulties, he became completely dependent on gastrostomy feeding. Airway visualisation showed large adenoids. An overnight oximetry was unremarkable despite coughing, snoring and frequent waking at night. Videofluoroscopy showed severely disordered swallow and a laryngeal penetration with small volumes of thickened fluids. His symptoms slowly improved but, after his second botulinum toxin A treatment in January 2005, he developed exacerbation of stridor and pneumonia and was hospitalised for 1 week. He underwent adenoidectomy in May 2005, but his condition showed no improvement. After receiving his third botulinum toxin A dose in August 2005, he developed vomiting and was subsequently hospitalised for pneumonia. In September 2005, laryngoscopy showed supraglottic collapse; he had airway obstruction. In December 2005, he received his fourth botulinum toxin dose and his stridor subsequently worsened. By March 2006, his stridor was present 24 hours a day and he had intercostal recession; his stridor worsened at the end of the day and improved with airway positioning manoeuvres. An overnight oximetry in April revealed significant nocturnal hypoxia. [Patient outcome not stated.] Author comment: "The temporal relationship of acute deterioration in laryngeal and pharyngeal function in this child to multilevel injections of [botulinum toxin A] are suggestive of a systemic side effect. It could be that on each injection occasion, enough [botulinum toxin A] reached the larynx and pharynx, to compromise function and result in stridor, dysphagia, pneumonia and feeding difficulties." Howell K, et al. Botulinum neurotoxin A: an unusual systemic effect. Journal of 801081547 Paediatrics and Child Health 43: 499-501, No. 6, Jun 2007 - Australia
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Reactions 28 Jul 2007 No. 1162
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