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Citation: Hristova AH. Impaired Neuronal Communication Syndrome (INCS) as Novel Neurological Side Effect to Journal of Bacteriology and Mycology

Authors:
  • Institute for Future Sciences and Medicine

Abstract

Based on the data of the 16 cases we report here, prior experience with side effects to botulinum, and the published literature, we define a novel syndrome as an adverse reaction to the toxin therapy which we named: Impaired Neuronal Communication Syndrome (INCS). We define INCS as a disease of toxin-induced impairment of neuronal connection and impaired mediators balance in the central, peripheral and/or autonomic nervous system with, most of the time, no identifiable anatomical cell damage. This syndrome differs from the reported in the literature autoimmune adverse reactions to the toxin, affecting the central (encephalitis) or the peripheral nervous system (inflammatory polyneuropathies, brachial plexitis etc). The major difference is that, in toxin-induced autoimmune syndromes, it is more likely to have positive findings in laboratory tests and imaging or on examination while, in INCS the majority of the patients have normal laboratory and imaging tests and neurological examination. This suggests that, in such cases, the clinical features and the proximity of the symptoms' occurrence to the toxin therapy are the main and often the only tools to achieve a correct diagnosis. We identify that the side effects from botulinum toxin therapy can be severe, persistent, and disabling. We suggest an algorithm for safer toxin use.
Citation: Hristova AH. Impaired Neuronal Communication Syndrome (INCS) as Novel Neurological Side Effect to
Botulinum Toxin Type A Therapy with 16 Case Reports. J Bacteriol Mycol. 2016; 3(4): 1035.
J Bacteriol Mycol - Volume 3 Issue 4 - 2016
ISSN : 2471-0172 | www.austinpublishinggroup.com
Hristova. © All rights are reserved
Journal of Bacteriology and Mycology
Open Access
Abstract
Based on the data of the 16 cases we report here, prior experience with side
effects to botulinum, and the published literature, we dene a novel syndrome
as an adverse reaction to the toxin therapy which we named: Impaired Neuronal
Communication Syndrome (INCS). We dene INCS as a disease of toxin-
induced impairment of neuronal connection and impaired mediators balance in
the central, peripheral and/or autonomic nervous system with, most of the time,
no identiable anatomical cell damage. This syndrome differs from the reported
in the literature autoimmune adverse reactions to the toxin, affecting the central
(encephalitis) or the peripheral nervous system (inammatory polyneuropathies,
brachial plexitis etc). The major difference is that, in toxin-induced autoimmune
syndromes, it is more likely to have positive ndings in laboratory tests and
imaging or on examination while, in INCS the majority of the patients have
normal laboratory and imaging tests and neurological examination. This
suggests that, in such cases, the clinical features and the proximity of the
symptoms’ occurrence to the toxin therapy are the main and often the only tools
to achieve a correct diagnosis. We identify that the side effects from botulinum
toxin therapy can be severe, persistent, and disabling. We suggest an algorithm
for safer toxin use.
Keywords: Botulinum toxin; Side effects; Adverse events; Central nervous
system; Autonomic nervous system; Impaired Neuronal Communication
Syndrome (INCS)
Abbreviations
3-4 DAP: 3-4 Diaminopyridine; Ach: Acetylcholine; BoNT/A:
Botulinum Neurotoxin Type A; CNS: Central Nervous System; EEG:
Electroencephalogram; ELISA: Enzyme Linked Immunosorbent
Assay; INCS: Impaired Neuronal Communication Syndrome; LD50:
Lethal Dose of the toxin that kills 50% of the mice population; SNAP-
25: Synaptosomal Associated Protein - 25.
Introduction
Botulinum Neurotoxin Type A (BoNT/A) was puried in
1928. ree forms of BoNT/A were approved for use in USA:
onabotulinumtoxinA: for therapeutic in 1989 and for cosmetic in
2002; abobotulinumtoxinA: for therapeutic and cosmetic in 2009
and incobotulinumtoxinA: for therapeutic in 2010 and for cosmetic
in 2011. Since then thousands of patients have been injected world-
wide, while the toxin sales have been increasing trough the decades.
Numerous double-blind trials have been conducted. e toxin therapy
was regarded as generally safe. In September 2009, aer 20 years of
use, a black-box warning for the toxin was issued indicating that
BoNT/A could cause death and disability. is is not unusual in type B
adverse events to drugs as dened in pharmacovigilance research [1],
indicating that, double blind studies oen cannot establish the long
term safety of a drug even aer decades of use. Type B adverse events
are events displaying phenomenology other than the well known and
expected reactions to a drug, known as type A events. Typically, type
Review Article
Impaired Neuronal Communication Syndrome (INCS) as
Novel Neurological Side Effect to Botulinum Toxin Type
A Therapy with 16 Case Reports
Hristova AH*
Institute for Future Sciences and Medicine, Virginia, USA
*Corresponding author: Hristova AH, Institute for
Future Sciences and Medicine, Virginia, USA
Received: August 15, 2016; Accepted: September 16,
2016; Published: September 19, 2016
B events require a signicant amount of adverse events reports before
a drug to side eect connection is established [1]. Historically, in such
cases, there are abnormal ndings in the laboratory, imaging or other
tests or in the clinical examination, facilitating the establishment of
a relationship. A good example of the above is the chloramphenicol-
induced aplastic anemia [2]. Unfortunately, in the case of BoNT/A,
we do not have readily available laboratory, imaging or other study
abnormalities to establish a relationship between an adverse event and
the toxin. Autopsies of people and animals who died from botulism
did not display specic changes to identify the toxin as cause of death
[3, 4]. Herrero et al. [5] sacriced monkeys to intra-venous injection
with the toxin and found no specic morphological changes. In
this article we demonstrate that, at present, the main and oen the
only tools to establish diagnosis are the symptoms proximity to the
toxin injection and the clinical picture which bares great similarity
across the patient’s population. We established the phenomenology
of a novel syndrome, as an adverse event syndrome to BoNT/A
and named it an “Impaired Neuronal Communication Syndrome”
(INCS). We suggest an algorithm for safer BoNT/A use.
Clinical Cases
All patients were consulted for their condition by the author over
a period of 4 years. Available data from other providers, imaging,
laboratory and test results have been included in the data summaries
(Tables 1a, 1b, 2a, 2b). e symptoms are graded in each case with one
J Bacteriol Mycol 3(4): id1035 (2016) - Page - 02
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Patient number 1 2 3 4 5 6 7 8
Demographics
Age 54 35 34 48 41 32 53 44
Gender F F F F F F F F
Toxin ONA ONA ONA ONA ONA ONA/ABO ONA ONA
Cosmetic/dose 117U (injected in
neck and face)
ONA1-30U
ONA2-30U
ONA3-49U
27U
ONA1:
unknown
ONA2:
unknown
given < 3
mo perior
ONA3: 30
units
V1: 25U
V2: 25U
V3: 50U
V4: 50U
ONA1: 10-24U
ABO1: 60U
ABO2: 60U
ONA11:25U
ONA1-30: (30-
35U)
ONA31: (30-
35U)
ONA32: (30-
35U)
ONA33: 10
units
no
Therapeutic/dose no no no no no no no
ONA1- 100****
ONA2- 120
ONA3- 200
migraines/neck
pain
Years of toxin
treatment 1st injection 3 years 1st Injection 9 months 2 years 5 years 12 years 3 years
Time to Symptoms
onset 10 minutes ONA1: 24 h
ONA2-7: none
ONA8: 2 h 1h
ONA1: 24 h
ONA2: none
ONA3:
minutes
ONA1: 2 months
ONA2: 2 months
ONA3: 1 month
ONA4: 5 h
ONA1 to B10:none
ABO1: couple of
weeks
ABO2: couple of
days
ONA11: 48-72h
ONA1-30:
none
ONA31: few
hours
ONA32: 30
minutes
ONA33: few
hours
ONA1: 48-72h
ONA2: none
ONA3: 48-72h
Symptoms
First Symptom Lightheaded
Tingling face
Ringing ear
ONA1;
headaches
ONA2-7-none
ONA8- inner
trembling
Profound
Tiredness
ONA1- SOB
ONA2- none
ONA3-
dizziness
R arm
tingling
ONA1: generalized
rash
ONA2: chest pain,
fatigue
ONA3: SOB, chest
pain
ONA4: burning
head
ONA1-10:none
ABO1: myoclonus,
insomnia
ABO2: insomnia,
vision, color
changes
ONA11:
myoclonus,
insomnia, vision
dystortion
ONA1-30:
none
ONA31:
anxiety, fatigue
ONA32:
palpitations
ONA33: heart
racing,
feeling of dying
ONA1: droopy
eyelid,
neck weakness
ONA2: no side
effects
ONA3: fatigue
Fatigue/endurance +++ +++ +++ +++ ++ +++ +++ +++
Central nervous
system +++ ++ ++ +++ +++ +++ + ++
Peripheral nervous
system +++ ++ + + +++ + + ++
Autonomic +++ +++ +++ +++ +++ ++ +++ +++
Psychiatric ++ + ++ +++ +++ +++ +++ ++
Hypothalamic
syndrome yes yes yes yes yes yes yes yes
Muscle weakness yes yes no yes no yes yes yes
Immune system
activation
markers and
symptoms
yes: small ber
polyneuropathy,
ulcers in mouth
yes: Eosinophils
elevated and
temp
99.9º F
no no yes: rash; CRP,
globulines and ANA
elevated
yes: blotchy, itchy
hands and chest
ANA elevated
yes: ANA
elevated yes: soar throat
3 days
Trophic changes yes yes no yes no yes no no
Specic Features
Sensitivity to food
and meds yes yes no no yes no yes yes
Crises and relapses yes yes no yes yes yes yes yes
Wax/ Wane of
Symptoms yes yes no yes yes yes yes yes
Increase rate of
Infections yes yes yes no no no no no
Table 1a: ANA: Anti-Nuclear Antibodies; CRP: C-reactive Protein; HA: Headaches; H: Hour; F: Female; ºF: Fahreinheit; M: Male; PET: Positron Emission Tomography;
R arm: Right arm; SOB: Shortness of Breath; WBC: White Blood Cells; Toxins: ABO: AbobotulinumtoxinA; INCO: IncobotulinumtoxinA; ONA: OnabotulinumtoxinA; the
number after the toxin indicated the number of treatment with the particular type botulinum and the sequence of treatments ; *Patient was injected with ABO to which
she had reaction and later with ONA when the disability occurred; **Patient received ller around the mouth the same day, ***After initial improvement over a year period
this patient’s symptoms worsened again after scombroid sh poisoning, **** First ONA injection was done together with lidocaine.
J Bacteriol Mycol 3(4): id1035 (2016) - Page - 03
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Reaction to prior
injections n/a yes n/a yes yes yes yes yes
Quality of life
Functionality before
toxin 100% 100% 100% 100% 100% 100% 100% 100%
Disability after the
toxin yes yes yes yes yes yes yes for 5 years yes
Recovered 100% no no yes in 4
months no no no yes in 5 years no
Patient number 9 10 11 12 13 14 15 16
Demographics
Age 38 34 43 41 32 53 36 27
Gender F F F F F F F M
Toxin ONA** ONA ONA ONA ONA ABO ONA ONA/INCO
Cosmetic/dose 20U 28U 16U 25U 26U 100U ONA1-6: 25U
(<3 mo apart) no
Therapeutic/dose no no no no no no
ONA7: 50 U
(injected for
armpit sweating
in 20 spots )
ONA1-5: 175U
ONA6: 190U
ONA7: 190U
INCO1: 190U
(injected for cervical
dystonia)
Years of toxin
treatment 1st injection 1st injection 1st injection 1st injection 1 injection 1 year 2 years 4 years
Time to Symptoms
onset 4h 24h minutes 72h 4h ABO1: none
ABO2: 72h
ONA 1-3: none
ONA 4-5: seven
days
ONA 6: hours
ONA 7: 24-48h
ONA1-5: several days
ONA6: several days
ONA7: several days
INCO1: 72h
Symptoms
First Symptom Burning in brain,
diarrhea, vomiting
chest pain
Head pressure
Palpitations
Numbness
head, nausea,
vomiting,
breathing,
swallowing
Heaviness
Forehead,
headaches
Numbness
of face
SOB
ABO1: none
ABO2:
Difculty
breathing
ONA 1-3: none
ONA 4-5:
SOB, urination
difculty
ONA 6: SOB,
loss of appetite,
malaise
ONA 7: Flu- like,
feeling of
suffocation
ONA1-5: anxiety, HA,
neck weakness
ONA6: SOB, HA (for 3
days)
ONA7: SOB, HA (for 12
days)
INCO1: SOB, swallow,
anxiety, speech,
symptoms persisted
Fatigue/endurance +++ +++ +++ +++ + +++ +++ +++
Central nervous
system ++ ++ +++ +++ ++ +++ ++ +
Peripheral nervous
system +++ -+ +++ ++ + ++ ++
Autonomic +++ +++ +++ +++ +++ +++ +++ +++
Psychiatric +++ +++ +++ +++ +++ +++ +++ +++
Hypothalamic
syndrome yes yes yes yes yes yes yes yes
Muscle weakness yes yes yes yes no yes no yes
Autoimmune
symptoms or
markers
yes: small ber
polyneuropathy
hives face and
hands
yes: anticar-
diolipin
antibody no no Yes, rash
forehead, C3
complement
yes:
botulinum
antibody
yes: elevated
ANA, WBC and
platelets
yes: asthma like
symptoms and rash,
PET scan increase
intake is thymus, tongue
ulcers
Trophic changes no no no no yes yes yes yes
Specic Features
Sensitivity to food
and meds yes yes no no yes yes yes no
Crises and relapses yes yes yes yes yes yes*** yes yes
Wax/ Wane of
Symptoms yes yes yes yes yes yes yes yes
Increase rate of
Infections no yes yes no no no yes no
Table 1b:
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to three pluses in order of their severity and prevalence. All patients
experienced multiple symptoms from each group with 12-25 range of
total number of symptoms per patient. All patients had clinical eects
from their injections. e demographics show signicant female
predominance due to the cosmetic use of the toxin in the majority
of the presented cases. In addition, most of the patients were injected
with onabotulinumtoxinA, likely because the drug has the longest
market presence. e relevant data from past and family history
and the abnormal ndings from the general and the neurological
examinations, done at time of presence of signicant complains, are
presented in Table 3a and 3b. e examination is oen normal or
minimally aected. e subtle positive signs can oen be missed if
fast or only a gross neurological examination is performed. We found
that clock drawing, pictures and animals naming and at times muscle
fatigability testing were useful tools in assessing patients’ status.
We composed and analyzed 9 groups of clinical symptoms as
phenomenology expression of INCS:
Central Nervous System (CNS)
Patients oen use the following expressions: “I am in a fog… …I
am in a bubble…I feel detached…My body is not listening to my
brain…I am disconnected…Somebody else is operating my body”.
e most common symptoms are impaired concentration, word
nding diculties, impairment of memory, signicant head pressure,
phono- and photophobia and inability to multitask. Processing speed
is decreased. Events happening at a faster speed are not perceived well,
such as: retrieving all information from a person speaking quickly or
from a group of people speaking at the same time reading and looking
at fast moving objects. Most of all, there is a mental fatigue which
oen leaves the patients debilitated and with the ability to only do
a few tasks before exhaustion sets in. Other reported symptoms in
order of frequency are: internal shaking, electric feeling in the head
or along the spine, headaches, episodes of speech arrest with duration
of 10-15 minutes, loss of smell, myoclonus, abnormal movements,
distortion of the visual elds, gait ataxia and tremors.
Peripheral nervous system
e most common symptoms are pain and/or paresthesia in
limbs, face and/or torso and a “buzzing” feeling in the nerves. Many
times the pain is severe and is described as, “crushed glass under my
skin” or “acid dripping”, leaving the patient suering 24/7. Feelings of
pins and needles, itching and numbness are less frequent symptoms,
but can be, as well, pronounced. Cranial nerves, such as the acoustic
nerve, can be aected with tinnitus, and the optic nerve with tunnel
vision. Maximum pain at the area of the injection is one sign which can
be used to establish connection to the toxin. Sensation disturbances
may occur in the vaginal area, without presence of infection.
Autonomic nervous system
Most common and disabling are the following symptoms:
shortness of breath, arrhythmia, heart racing, palpitations, chest
pain, dizziness, dry mouth, dry eyes and stuy ears, nose and
head. Sometimes the intensity is severe, especially of the shortness
of breath. e patents describe it as “not being able to take a deep
breath”, “involuntary arrest of breathing for several seconds” and
“need to constantly remind the self to breathe”. When present and
intense, the later symptom can linger for years deeply aecting the
quality of life of the patient. Other reported symptoms are: urine
incontinence, frequent urination, straining on initiation of urination,
nausea, vomiting, constipation, diarrhea, blurred vision, eye strain,
icy cold limbs, night sweats, abdominal pain, runny nose, hoarseness
and chest pressure. Constipation can be very severe.
Psychiatric
Psychiatric symptoms are very common and debilitating such as
severe anxiety, panic attacks, feeling desperate, hopeless, negative and
xated on the symptoms. ere is a deep feeling that something is
wrong and the patients feel terried or fearful for a long time. e
patient’s whole world is absorbed by the disease. It is common for the
patient to wake up at night with agonizing fear that death is imminent.
Usually, depression sets in as the patient is unable to receive help or
acknowledgment of his/her symptoms from others or, at times, from
the medical providers. Psychosis is less common but no less crippling.
One patient had constant visions of killing others, seeing aliens and
other people in her room.
Hypothalamic syndrome
Weight loss, loss of appetite, insomnia, reduction of libido,
change in menses or sperm, change in tolerance of cold and warm, hot
ashes and increased thirst are frequent symptoms. Increased hunger
is rare. Weight loss (6-35 pounds), though most of the time transient,
could be extreme at times. Insomnia is oen disabling and prolonged.
Amenorrhea can last for months. e one male patient reported in
this series said that his sperm looked like water for one year aer the
occurrence of the side eects. Patient #10 had initial normal thyroid
tests and then pattern suggesting “central” hypothyroidism.
Fatigue, lack of endurance, muscle twitches and muscle
stiffness
Fatigue is usually profound and present in all patients. Sometimes
even the slightest eort tires the patients, such as holding a book
for several minutes when reading or rigorously stirring tea. Muscle
stiness and tightness are very common and disturbing to the
patients. Myoclonic jerks and other twitches occur, but are rare.
Muscle weakness
It is very important to note, that although the patients experience
and report lack of muscle power and complain of weakness, the
muscle power on manual testing is almost always normal suggesting
Reaction to prior
injections n/a n/a n/a n/a n/a no yes yes
Quality of life
Functionality before
toxin 100% 100% 100% 100% 100% 100% 100% 100%
Disability after the
toxin yes yes yes yes yes yes yes yes
Recovered no no no no yes in 4 mo no no no
J Bacteriol Mycol 3(4): id1035 (2016) - Page - 05
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Table 2a: Ab: antibody; ABG: Arterial Blood Gas; Ach: acetylcholine; AchR: Acetylcholine Receptors; ALT: Alanine Aminotransferase; ANA: Anti-Nuclear Antibody;
AP: Alkaline Phosphatase, AST: Aspartate Aminotransferase; BNP: B type Natriuretic Peptide; C-ANCA: Cytoplasmic Anti-Neutrophil Cytoplasmic Antibody;
CD57+NK: CD+57 Natural Killers Lymphocytes; C and L spine: cervical and lumbar spine; C1Q: anti-ganglioside C1Q antibody; CPK: Creatine Phosphokinase; CRF:
Corticotrophin Release Factor; CRH: Corticotrophin Release Hormone; CRMP Ab: collapsin response mediator protein antibody; CRP: C-reactive Protein; CT: Computer
Tomography; CXR: Chest X-ray; DHEA: Didehydroepiandrosterone; ds-DNA: Anti-Double Stranded DNA; ECHO: Echocardiography; ECG: Electrocardiogram;
EEG: Electroencephalogram; EMG: Electromyography; ENT: Ear Nose Throat; ESR: Erythrocyte Sedimentation Rate; FSH: Follicle Stimulating Hormone; FVC:
Forced Vital Capacity; G-6PD: Glucose-6-Phosphate Dehydrogenase; GAD-65: Glutamic Acid Decarboxilase; GGT: Gamma Glutamyl Transpeptidase; GM1a: anti-
ganglioside GM1a antibody; GM1: anti-ganglioside GM1 antibody; GM2: anti-ganglioside GM2 antibody; GQ1B: anti-ganglioside GQ1B antibody; Hb: hemoglobin.
HbA1C: hemoglobin A1C; HGC: Human Gonadotropic Hormone; HIV: Human Immunodeciency Virus; HSV1: Herpes Simplex Virus type 1; HSV2: Herpes Simplex
Virus type 2; Ht: Hematocrit; HbA1C: Hemoglobin A1C; IEF: Immuno-Electrophoresis; IgM: Immunoglobulin M; INR: International Normalized Ratio; LH: Luteinizing
Hormone; LDL: Low Density Lipoprotein; LP: Lumbar Puncture; Mg: Magnesium, MMA: Methylmalonic Acid; MRI: Magnetic Resonance Imaging; MTHFR: Methyl-
Enetetrahydrofolate Reductase; MUSK: Anti-Muscle Specic Kinase Antibody; Na: Sodium; NIF: Negative Inspiratory Force; O2 Sat: Oxygen saturation; P-ANCA:
Perinuclear Anti-Neutrophil Cytoplasmic Antibody; PCA: Anti-Parietal Cell Antibody; PET: Positron Emission Tomography; PFT: Pulmonary Function Test; PT:
Prothrombin Time; PTH: Parathyroid Hormone; RBC: Red Blood Cells; RF: Rheumatoid Factor; RNP: Anti-Ribonucleoprotein Antibody; RPR: Rapid Plasma Reagins;
SCL70: Scleroderma 70 antibody; SPEP: Serum Protein Electrophoresis; SSA: Anti-Sjogren Syndrome A Antibody; SSB: Anti-Sjogren Syndrome B Antibody; TRH:
Thyroid Releasing Hormone; TSH: Thyroid Stimulating Hormone; US abdo: Ultrasound Abdomen; vit B12: vitamin B12; vit B6: vitamin B6; vit D3: vitamin D3; WBC:
White Blood Cell Count; *CD57+NK have been reported to be lower in chronic diseases such as Lyme compared to normal controls.
Patient # 1 2 3 4 5 6 7 8
Positive
test
results
Skin biopsy:
positive for
small ber
polyneuropathy,
ENT (atrophy of
vocal cords)
Cholesterol 209
(<200)
ECG: ST and T abnormal,
possible posterior
ischemia,
anion gap 18 (7-16)
platelets 134 (150-350)
prolactin 4.1 (4.8-23.3),
estrogen 119 (156-350)
RBC 5.44 (4-5.2), Hb
15.7 (12-15), Ht 47.1 (36-
46), Eosinophils: 3.3 (<2)
2 days after the injection
and 4.6 (<2) during a
crisis, FVC 1.61L (3-5),
NIF: 40 (>60)
Urine blood
2+
Folate 201
(>280)
supple-
mented
WBC: 10.67 (4.5-
10), neutrophils
0.74 (<0.65),
lymphocytes
0.19 (>20), CRP
25 (<1), globulin
33 (<30), ANA
1:60 (<1:40),
(ECG holter:
random episodes
of tachycardia),
heart rate
variability 58
(60-80), thermo
paraspinal scan:
inammation C1-
C3 level
ANA 1:160
MRI head: 6 mm white matter
lesion in the right centrum
semiovale
cortisol 27.74H (2.3-11.9)
Vital Capacity
2.1L (2.9L)
ANA 1:80
speckled,
HCO3 30.2
high (23-27),
Indirect
bilirubin 0.9
(0.2-0.7)
CD 57+NK: 75
(60-350)*
Ionized
calcium actual
1.31(1.17-
1.29)
Negative
test
results
Electrolytes,
calcium, glucose,
albumin,
globulin, WBC,
liver enzymes,
ds DNA bilirubin,
ESR, CRP, LDL
triglycerides,
TSH, T3, T4
free, ANA,
triglycerides,
MRI of brain
Electrolytes, glucose,
creatinine, liver enzymes,
urine, CPK, copper, vit
B12, TSH, Mg, HGC,
antibodies: MUSK,
dsDNA, ANA, AchR
blocking and modulating
vit D3, phosphate,
osmolality, magnesium,
CRP, ESR, C1 esterase
inhibitor, ANA, TRH,
CRF, CRH, GH-RH,
antidiuretic hormone,
plasma
Catecholamines
(norepinephrin,
epinephrine, dopamine),
testosterone, aldosterone,
estriol
Electrolytes,
glucose,
creatinine,
liver
enzymes,
WBC
Electrolytes
creatinine,
glucose,
iron,
ferritin,
calcium,
TSH, free
T4, Mg,
vit D3, vit
B12,
Gliandin
Ab,
ANA,SSA,
SSB, Ht
Electrolytes,
liver enzymes,
bilirubin, acetone,
transferrin,
amylase, lipase,
CPK, lipid prole,
albumin, RF, anti
ds DNA, anti-
Smith Ab, TSH,
T3 and T4, vit D3,
iron, pulmonary
function test,
cardiac stress
test, MRI brain,
EEG, ECG
Electrolytes, WBC, creatinine,
liver enzymes,CRP, ESR,
vit D3, vit B12, MMA,Vit
B1ferritin, Hb A1C, glucose,
thyroid prole, DHEA,FSH,L
H,progesterone,testosteron,
glucose, Lyme, gliandin Ab,
lead,
mercury, copper, complement,
Raji cells, Immuno-globulins,
food allergies, ova and
parasites
G-6PD, MTHFR, SPEP,
antibodies:SSA, SSB,Anti-
Smith, anti-Jo, Scl 70,
RNP, Ach R Ab, P-ANCA,
C-ANCA,GQ1B Ab,
GM1a, GM1, GM2,
paraneoplastic panel,
rheumatoid factor, EMG, EEG,
tilt table, bone density
Electrolytes,
creatinine,
glucose, WBC,
Hb, AST, ALT,
ESR, CRP,
TSH, globulin,
aldolase,
lyme, copper,
venous
ABG, SPEP,
TSH, CPK
complement
C3 and C4,
RF, RPR,
BMP, vit
B12, folate,
INR, PT, liver
enzymes,
Lyme
Electrolytes,
glucose,
WBC,
calcium,
Mg, lactate,
pH, urea,
creatinine,
CPK, CRP,
TSH, MRI c
spine: minor
disk bulging
in mid cervical
level, normal
cervical cord
more central than peripheral nervous system origin of the symptom.
If present, the weakness is usually mild, transient and easily can be
missed if more gross or quick neurological examination is carried out,
especially because most of the times the patients look “generally well”.
e most common features are fatigability of the neck and proximal
hip exor muscles, ptosis and swallowing decit. e swallowing
decit may persist for months though rarely were swallowing studies
performed.
Atrophic syndrome
Patients complain of skin atrophy, subcutaneous tissue loss,
lumping of the subcutaneous tissue, hair loss and nail impairment.
Loss of muscle mass, at times signicant, usually occurs in the rst
year of the syndrome, though it can occur later too.
Autoimmune syndromes
Seventy-ve percent of the patients have some autoimmune
marker or clinical symptom suggestive of immune activation at some
time during the course of their disease. However, those markers and
symptoms are usually non-specic and many times only transiently
present. It is important to note that, at times, the markers can
reappear shortly during subsequent bouts of the disease. In these
case-series, the only persistent and visible damage over the nervous
system had been the presence of small ber polyneuropathy with skin
J Bacteriol Mycol 3(4): id1035 (2016) - Page - 06
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Patient # 9 10 11 12 13 14 15 16
Positive
test results
Skin biopsy:
small ber
polyneuropathy
ECG
depression
with rate 120,
H pylori and
Blastocystis
homini positive
- 1.5 years
after the
injection.
anti-cardiolipin
Ab (one
pregnancy
before Botox,
and frozen
embrio.
After Botox:
Miscarriage at
rst trimester
when the
positive anti-
cardiolipin
Ab were
discovered.
Thyroid initially
normal later
low TSH-0.87
U/ml (1.8-3),
T3-82 ng/dL
(100-180) and
T4-4.7 ng/dL
(6-12)
ECG: sinus
arrhythmia ST
suppression,
Partial block
V3, 02
saturation 89-
90%
(pre-Botox
ECG normal)
Holter ECG
extrasystoli with
sinus tachycardia
of 90.
C3
complement79
(90-180)
Botulinum
blocking Ab
acetylcholine
esterase 50.4
(36.7-49.2)
Whole body
thermography:
multiple foci of
inammation
ECG: sinus
tachycardia
Cardiac monitor:
sinus tachycardia
episodes up to 140
later normal ECG,
ANA 1:160 (<1:40)
2 mo after injection,
3 mo later 1:320
homogeneous,
1 month later
normal, low iron sat
(supplemented)
HSV1 IgG 1.13
(>1.10), IgM 1.14
(<1.10), LDL 134
(<130), cholesterol
213 (200), CRP
1.3 (<1), D3 24
(>30) corrected with
supplements, WBC
11 (3.8-10.8), Lyme
23.7 (24-44), platelets
448 (130-400), Na
134 (135-146) only
once, US bladder:
slightly elevated
residual urine 72 ml,
polysomnography:
no dissaturation,
one central apnea
episode and 13
arousals per h.
ALT 61 (7-
55), PET scan
increase intake
of radioactive
glucose
in thymus
which was
not enlarged,
diaphragmatic
weakness as
per pulmology
possible
phrenic nerve
dysfunction, in
hospital record
suggests vagus
dysfunction,
ECG: sinus
tachycardia 107
and numerous
examinations
with pulse
recorded
between 103 and
114,
sweat test
abnormal
Negative
test results
Electrolytes,
glucose, WBC, vit
B12, MMA, SPEP,
IEF, Hb A1C, vit
B6, Antibodies:
ANA, AchR,
paraneoplastic
glandin,
tissue trans-
glucatminase,
Ca P/Q, Purkinje,
amphiphysine,
CRMP, SSA, SSB,
Smith, Scl70,
RNP, MRI brain
and spine, EMG
Electrolytes,
calcium,
glucose,
creatinine,
WBC,
bilirubine,
CRP, CPK,
troponins,
BNP, drug
screen, urine
analysis, HIV
1 and 2, RPR,
Hepatitis A, B,
C, prolactin,
hemoglobin,
liver enzymes,
ESR,
antibodies:
ANA, dsDNA,
SSA, SSB,
Scl70, anti-
Smith, anti-
centomere,
CXR, X-ray
abdomen, CT
head
Creatinine,
electrolytes,
glucose, WBC,
ECHO
WBC, Hb,
glucose,
creatinine,
potassium,
electrolytes,
vit D, vit B12,
CPK, Calcium,
Homocysteine,
liver enzymes,
troponins, TSH,
T3, T4 cardiac
enzymes, Lyme
test, CT head with
contrast
Electrolytes,
creatinine,
glucose, WBC,
CRP, ANA, C4
and total
complement,
ESR, WBC, ANA
Electrolytes,
glucose, WBC,
Raji cells, C1Q
complement: C3,
C4, antibodies:
Lyme**, anti-ds
DNA, CXR, MRI
head,
Electrolytes, glucose,
protein, Hb A1C,
iron, bilirubin, 02 Sat,
liver enzymes, HIV,
folic acid, protein,
RPR, RF, TSH, T3
uptake, free T4,
hepatitis A,B,C, ESR,
D-dimer, HSV2,
complement C3,
C4, CH50, vit B12,
vit D3, triglycerides,
PTH antibodies:
thyroglobuline
chlamydia, ds
DNA, SSA, SSB,
anti-Smith, SCL70,
Jo-1, peroxidase,
centromere, histone,
chromatin, Ach
binding, MUSK;
catecholamines urine,
allergy test, MRI brain
with contrast, PFT’s
x3, allergy tests,
ultrasound abdomen,
CXR, hearing test,
Ishihara color test,
EEG, cardiac stress
test, US abdo, ENT:
unknown etiology of
sinus swelling
WBC,
electrolytes,
glucose,
D-dimer,
calcium, copper,
troponin.
bilirubin,
creatinine, GGT,
ALT, AP, TSH
eosinophils,
antibodies:
AchR ganglionic,
binding,
amphiphisin,
GAD 65,
neuronal K
channels, P/Q
calcium, PCA-
1,2,3, striatal
muscle, LP
normal with
no oligoclonal
bands, CXR,
MRI L spine,
CT head, video
swallowing,
EEG 48 h,
PFT without
methacholine
challenge, stress
ECHO, EMG/
NCS, tilt table
test. MRI c spine
after the rst
injection: minimal
degenerative
changes.
Table 2b:
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biopsy performed when the patient had signicant peripheral nervous
system symptoms. Unfortunately, this was done only in 13.3% of the
patients who had clinical symptoms of peripheral nervous system
involvement. Flu-like symptoms are rare.
Other prominent features
Increased frequency of infections: One-third of the patients have
increased rate of infections. e most common are upper respiratory
tract infections, pneumonia, urinary tract infections and sinusitis.
Activation of dormant diseases such as herpes may occur.
Sensitivity to food and medications: is peculiar symptom
is present in 62.5% of the patients. e sensitivity is especially
pronounced to serotonin uptake inhibitors, coee, sugar and alcohol
which almost uniformly worsen the symptoms of the patients.
Steroids either worsen the symptoms or are ineective. Patients
have adverse reactions to most of the CNS modulating drugs
with the exception of benzodiazepines (alprazolam, lorazepam,
clonazepam) in a low dose, which helped some of the psychiatric
symptoms in some patients. Here is the list of the drugs which the
reported patients were not able to tolerate: paroxetine, uoxetine,
sertraline, pregabaline, escitalopram, duloxetine, desvenlafaxine,
trihexyphenidyl, lamotrigine and quetiapine. Usually, with time and
attempted treatments, the patients become afraid of trying any new
drugs or therapies.
Crises and waxing and waning of the symptoms: is is a
uniform feature throughout the population. e patients have bad and
good days with uctuation of their symptoms. Dierent symptoms
can be more pronounced at dierent times. In addition, there are
sudden crises where some or all symptoms worsen. We identied
common triggers such as medications, food, pushing through fatigue
and stress. Most patients become very fragile and afraid of activity,
food, and medications since the reaction is oen unpredictable and
can be severe. Crises continue to occur many years aer the injection,
with new symptoms developing over time, though the majority of the
new symptoms develop during the rst year.
Symptoms onset: e symptoms onset ranges from minutes to
weeks with most common frame of time onset 24-72 hours.
Years of toxin treatment and reaction to prior injections: Our
data demonstrate that a generalized spread of the toxin can occur even
aer years of uneventful toxin therapy. Patient #7 had 30 successful
treatments over a decade before the adverse events occurred. Prior
uneventful injections cannot be a predictor for toxin safety, because
in our experience, generalized spread can occur at any time and with
any injection. Forty-four percent of the patients develop a reaction
aer their rst time injection. From those who had more than
one injection, 50% had an adverse event to prior injections which
remained unrecognized and lead to devastating eects with next
injections. Our data suggests that with each subsequent toxin reaction
the time of symptoms onset may shorten, as the patient’s immune
system sensitizes further to the toxin. Some of the injections were
done together with Lidocaine which increases the injected volume
and, with this, the possibility of generalized spread. Some patients
Past Medical History Family History General and Neurological Examination
Case 1
Chronic obstructive pulmonary disease
for 15 years: occasional inhaler use, rare
premature ventricular contractions with normal
angiography, allergies to dogs and melons,
occasional headaches, smoker
Son: asthma
Sister, father and
grand mother:
cancer
Dehydration: skin fold: 2 seconds; word recall 1/3 on 1st attempt, 3/3 on second,
verbal paraphasias, able to draw clock with signicant contemplation time, names
13 animals in 60 seconds, though 12 is the norm, people of her age and education
usually generate 20, difculty naming rare objects, hoarse voice, right eye vision:
20/30, left eye vision: 20/25, bilateral spasm and pain on palpation of trapezius,
levator scapulae, scalene; reexes 3+ with questionable Babinski on the left and
tonic big toe extension on the right.
Case 2 Asymptomatic cervical disk, benign neuromas
of skull, allergy to dog fur Father and grand
father: cancer
Pin thin, signicant muscle wasting proximal>distal, during conversation slow
retrieving of some words, dry eye requiring frequent articial tears, 10 degree
lateral head tilt to the right, 4+/5 proximal leg weakness with some fatigability
Case 3
Cushing like syndrome after signicant stress
in life with normal magnetic resonance imaging
head, the condition resolved 2-3 years before
the toxin therapy
Cancer in father and
mother difculty in retrieving words but able to execute the mental tasks correctly
Case 4
Postural orthostatic tachycardia syndrome
with dizziness when standing up and some
fatigue, able to work 30 or more hours before
the toxin injection, melanoma left arm: cured
surgically, allergies: seasonal, nuts, sea food
and mushrooms
Brother: ulcerative
colitis, father: cancer
Pulse increases from 87 to 95 after standing up, hair and nails very dry, some skin
thinning and atrophy, minimal tiredness of the proximal legs, signicant lack of
endurance: the patient became profoundly exhausted after 10 minutes examination
Case 5 None Grand mother with
cancer Normal
Case 6
Anorexia and bulimia in college, at present
some bulimia binges but fully functional,
alcoholism in college (sober for one year
before the toxin therapy)
Multiple family
members with
cancer
When speaking some trouble nding words, pupils sluggish and not fully
contracting to strong light
Case 7
Post-traumatic splenectomy decades before
the toxin therapy, 3 miscarriages in the 1st
trimester with 6 living children birth after,
breast implants
Mother with
autoimmune
disease, father with
cancer
In wheelchair, cannot sit more then 10-15 minutes due to fatigue and pain. Visible
pain and discomfort with any movement. 4+ reexes, with bilateral positive
Babinski, one clonic bit on the right, tingling in the legs on Lassegue test, L’Hermitte
sign positive on neck exion, can sit only if the back of the head is supported,
needs two people’s support to transfer to bed.
Case 8
Endometriosis proven with laparoscopy,
glucose intolerance, 90% hearing loss on
the right from birth, esophageal dysmotility,
neck pain with some headaches for which the
patient was injected with the toxin
Grand mother with
leukemia, father with
cancer
Pupils reactive and unequal: 3 mm on the left, 5 mm on the right, difculty elevating
the left eyebrow, hyperreexia in all four limbs with normal jaw jerk, presence of
cross abductors and foot clonus bilaterally; hearing decreased on the right(old)
Table 3a:
J Bacteriol Mycol 3(4): id1035 (2016) - Page - 08
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were injected more frequently than the recommended 3-month
inter-injection interval, which may have created a cumulative eect
and an unnecessary stimulation of the patient’s immune system.
Some patients were injected as “models” during BoNT/A conferences
with no prior establishment of doctor to patient report and without
documentation for the event. Others were given BoNT/A because
it was oered for free to the sta at injector’s clinics during drug
representatives visits.
Functionality, disability, course of disease and prognosis: Before
the BoNT/A therapy, all patients were 100% functional and highly
active individuals, apart from patient #4 who had mild pre-morbid
impairment due to postural orthostatic tachycardia syndrome. In
all patients, disability occurred aer BoNT/A therapy with duration
from months to years (at the present moment of observation it is
8 years or more). e disability is oen signicant: patient #7 was
wheelchair bound for 1.5 years. e maximum disability duration is
unknown at present. Many patients loose their jobs and relationships.
Apart from the 3 patients who recovered completely (19%), all others
continued to have symptoms for years aer the injection. ough,
in our experience, mild and slow yearly improvement takes place as
the toxin is cleared from the system, the majority of the patients do
not reach his/her pre-morbid state of health at 5-6 years time mark
aer the last injection. e only BoNT/A condition that seems to
persist over the years, with no or very little improvement, is the small
ber polyneuropathy, since it is an auto-immune disease. In our
experience, if the patients have no yearly (even slow) improvement
of their symptoms in the rst 3-5 years, the prognosis for recovery
is less favorable. Since the syndrome is not yet well recognized, it is
not surprising that when a physician encounters normal neurological
examination, normal or minimally positive laboratory results and
normal imaging studies in the face of multiple patient’s complains,
the symptoms are assumed to be due to anxiety or somatization. is,
oen, leads to referral to psychiatry or to the start of psychiatric drugs
which then usually leads to worsening of the symptoms. e patients
oen go from doctor to doctor seeking help. ousands of dollars
worth of investigations are conducted, with little or no help or relief
from their symptoms and/or establishment of the true diagnosis.
e majority of the cases reported here were admitted to a hospital
or ER at least once during the course of their disease. Many times
the aected patients end up alone, depressed, broken and terried,
prisoners to their homes with restricted social contacts and very
Past Medical History Family History General and Neurological Examination
Case 9
Hypothyroidism: thyroid hormones before the toxin therapy: thyroid
stimulating hormone: normal, T3 1.87 ng/dl (2-4.90), T4: 0.71 ng/
dl (0.76-1.6), vagal syncope since teenage, 24 000 premature
ventricular contractions on 24 hours heart holter not responding to
ablation but treated successfully with beta blockers, mild essential
tremor
Father with cancer
Word registration 2/3 on rst attempt, and 3/3 on second,
29 animals in the rst 30 seconds, no animals generated
despite signicant mental strain in the next 20 seconds and
a few more animals named in the last 10 seconds, 5-/5 tiring
weakness of neck exion and in the proximal legs, mild
right>left and postural>action hands tremor, draws spirals
with mild bilateral tremor (due to presence of old and mild
essential tremor)
Case 10
one successful in vitro fertilization and natural birth before toxin
therapy, one miscarriage after toxin therapy when anti-cardiolipin
antibodies were found positive. Initial 90% recovery from the toxin
syndrome but then relapsed after the second in vitro fertilization, mild
asthma at age 8
Father: cancer
2/3 words recall at 5 minutes, literal paraphasias, visual-
spatial abnormalities on clock drawing, able to draw it
right only on 5th attempt, names less frequent objects with
signicant delay, reexes 2+ in the upper and 1+ in the
lower limbs.
Case 11 Controlled hypothyroidism, left elbow reconstruction after trauma with
normal muscle strength, right breast lumpectomy Cancer in the family
Left eye afferent like papillary reaction with normal vision,
hearing decreased on the right to ngers rub, minimal facial
weakness: cannot hold air in mouth with cheek pressure,
4/5 neck and hip exion weakness, 3+ reexes, decreased
speed of foot tapping bilaterally
Case 12 Cancer of uterine cervix 8 years before the toxin therapy: surgically
healed with conization, at age 5 left leg osteoid osteoma: cured
surgically Non-relevant Normal
Case 13 3 months post-partum depression, generalized anxiety and
compulsive cleaning, one week before the toxin therapy had a swollen
lymph node in the neck which cleared spontaneously Father: cancer Pulse 90, normal neurological examination
Case 14 None
Father and sister:
major depression,
3 family members
with cancer
Slight fatigability of neck exion, minimal dysmetria on
nger-to-nose test, slight reduction of vibration sense in legs
Case 15 None Father: depression
Grand mother:
cancer Normal
Case 16
At age 12 and 18 months episodes of neck and head xation with 2
days duration, hands xation in claw position for seconds or minutes
(suggesting elements of generalized dystonia), social anxiety: treated,
Helicobacter pilory ulcer: treated and cured, Hepatitis B (active
carrier state as per gastro-enterology consult: positive e and surface
antigene, vial load 116 UI/ml. Patient asymptomatic before the
toxin therapy. The hepatitis virus discovered after the toxin injection.
Cervical dystonia after one dose of metoclopramide. Cholecystectomy
after the toxin therapy to relieve toxin related symptoms with only
minor relief from the procedure. Smoker. Magnetic resonance
imaging head before toxin therapy: non-specic T2 lesion in right
external capsule most likely due to peri-natal trauma, which remained
unchanged after the toxin therapy (on second imaging).
Essential tremor and
epilepsy in family,
Father and sister
with hepatitis
Severe rash: red pimples blanching to some extent, on the
back and upper chest (persistent for months) frequent throat
clearing and coughing during the examination, some visual-
spatial distortion on clock drawing, named a pretzel a snake,
3+ reexes and tandem difculties.
Table 3b:
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few people who believe them. e impact of INCS on the patients’
quality of life is enormous. From the three patients who recovered,
patient #3 and #13 came to see me within 1-2 months from the
onset of the adverse event. I advised them not to inject the toxin
again, not to vaccinate, I put them on activated charcoal, echinacea
and diet therapy and supported them emotionally. Patient number
#7 did daily enemas with activated charcoal and coee, in slow dose
increments reaching a maximum of two table spoons of charcoal in
3 cups of coee. e treatment persisted for 1.5 years and the patient
did not stop the therapy when temporary worsening of her symptoms
occurred aer each enema. However, there were patients who did not
respond to charcoal/echinacea therapy suggesting that there is likely
a subpopulation in this patients’ group. For example, charcoal may
worsen patient’s symptoms if severe constipation is present, since
no elimination can occur and toxin re-absorption from the gastro-
intestinal tract and secondary hematogenic spread may occur.
erapy: All therapies are in a research stage of development.
Here is a list of modalities which helped some of the patients reported
here: Diet: gluten free, organic, vegan; chlorella; celery juicing;
abstinence from sugar, alcohol and caeine; avoidance of CNS
modulating drugs, with the exception of benzodiazepines, which
can be used in small doses for anxiety and panic attacks therapy;
bananas (likely because of the high potassium content); benadryl
(the symptoms in many patients suggest high histamine state);
aspirin (for the small ber polyneuropathy); valerian root (for the
internal shaking); magnesium gluconate (for the muscle tightness
and spasms); hyperbaric oxygenation (each treatment may induce
several hours of healing crisis with temporary worsening before
improvement occurs); activated charcoal; and echinacea.
Discussion, Hypotheses and Algorithm
Discussion and hypotheses of the phenomenology of
INCS
Central nervous system: Research has established that
botulinum can block many mediators in CNS [6- 9], though its
preference is upon the cholinergic pathways. On central level, the
peripheral acetylcholine (Ach) specicity is lost suggesting that the
target of botulinum is common to many, and may be all central
neurons of mammals as Bigalke et al. concluded [10]. Ach plays a
role in neural plasticity, word nding, concentration, attention,
learning, abstract thinking, creativity, brain speed processing, noise/
signal ratio improvement and intra-cortical transfer of information.
It is not a surprise, that the patients presented here frequently
display cognitive deciency. Luvisetto et al. [11] injected the brain
ventricles of live mice with botulinum and demonstrated that the
animals produced dementia-like features. Some of the important
principles of CNS functions are mediators’ balance and neuronal
nets interactions. When one mediator pathway is impaired the brain
adapts by altering the remaining mediators balance. Most of the
patients presented here exhibit combined features of depletion of
some mediators and increment of others, such as: Ach depletion with
impaired concentration, memory, focus, learning, thinking clearly
and coherently, recall and ability to process information; dopamine
depletion with aection of memory, attention and concentration and
problem-solving, slowness of movement and processing, low libido,
nausea, vomiting, lack of appetite and depression; hyper-adrenergic
state with rapid heartbeat, insomnia, fatigue, headaches, anxiety,
panic attacks, sweating, frequent or impaired onset of urination,
thirst, weight loss and constipation; and histaminergic state with
skin rash, runny nose, diarrhea, nausea, vomiting, cough, broncho-
constriction and vasodilation. In our experience, it is impossible to
predict which mediator systems will be aected and to what extent in
a particular patient, but the clinical symptoms may guide us to which
are the main mediator systems involved in each case. Russell et al. [12]
demonstrate that rats with 9 months diet- induced hypocholinergic
state (via a choline intake restriction) do not recover aer cessation
of the diet restriction and continue to display memory impairment
and hyperalgesia despite the fact that the biochemical parameters
recovered. e authors suggested the presence of adaptive CNS
changes as an etiology of the condition. is data sheds some light
on why cognitive impairment and other symptoms may persist for so
long in many of the cases presented here.
Peripheral nervous system: e symptoms of peripheral nervous
system involvement suggest autoimmune process aecting the small
bers conrmed with skin biopsy in two patients. Increased pain
perception due to prolonged hypocholinergic state [12] may be in
play as well.
Autonomic nervous system: It is well established that botulinum
aects the motor and the autonomic bers to equal extent. e
toxin can spread via blood and retrograde axonal transport through
both motor and sensory nerves [13-15]. Vagus nerve is the major
autonomic nerve in the body, therefore blocking it may create hyper-
sympathetic tone in the aected organs with symptoms of tachycardia,
nausea, diarrhea, chest pain, weight loss, stomach pain and spasms,
poor digestion, and dicult urine control which were frequently
experienced by the presented cases. In addition, the toxin acts on the
potassium channels [10] on which the heart is rich. Cardiac deaths
aer botulinum therapy have been reported in the post-marketing
period (Botox® insert). Blocking the vagus nerve can also, aect
the related central pathways such as brainstem, hypothalamus and
limbic system. e normal breathing studies, performed during time
of signicant breathing problems in some of the presented patients,
suggested a central breathing pacemaker impairment and central
hypoventilation problem similar but not equal to Ondine’s curse
syndrome. Only one patient had a polysomnography demonstrating
a central apnea episode without desaturation. e vital capacity, the
forced vital capacity and the negative inspiratory pressure are rarely
measured, while they may be a helpful tool when signicant shortness
of breath is present. Stone et al. demonstrated that locally applied
toxin leads to long lasting arteriolar dilatation which may explain the
common complaint of nose, head, ears or sinuses congestion, without
presence of infection. It is well established that Ach plays a role in the
autoregulation of the cerebral blood ow.
Psychiatric: Deciency in acetylcholinergic pathways has been
related to anxiety, bipolar behavior and delirium. We speculate that
retrograde toxin spread to the limbic system or shi in the global
brain mediator balance are possible causes of psychiatric symptoms
experienced in these patients’ series. Hyper-histaminic state has been
considered in schizophrenia patients and there is a report of a patient
who’s mental illness responded well to treatment with the histamine
receptor antagonist famotidine [18].
J Bacteriol Mycol 3(4): id1035 (2016) - Page - 010
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Hypothalamic syndrome: eoretically, the toxin can reach
hypothalamus via retrograde vagus or cranial nerves’ transport, or
via blood spread. ough the blood brain barrier protects the brain,
it is thinned at the hypothalamus in order for monitoring of body
homeostasis to occur. Boro et al. [16] demonstrated that radio-
labeled botulinum crosses the blood brain barrier. irunavukkarasu
et al. [17] showed that, once injected, the toxin alters the expression
of 227 genes including those responsible for transmigration of
monocytes and T-cells across the blood brain barrier. In respect to
the alteration of the mediator balance, the highest concentration of
histamine in the brain is in the hypothalamus. Histamine is involved
in the regulation of cognition, circadian rhythms (including sleep) and
neuroendocrine balance [18]. Increased concentration of histamine is
reported in serum and spinal uid of Alzheimer dementia patients
[18].
Fatigue, lack of endurance, muscle twitches and muscle
stiness: e pathophysiology of fatigue has always been a
challenging and complex question. e symptom has been reported
to persist from 6 to 13.5 years aer botulinum food poisoning
[19,20]. It is likely mediated by cholinoreceptors in the ventro-
medial hypothalamus [21]. Alteration of brain circulation may
be involved too [22]. Studies on chronic fatigue syndrome suggest
involvement of hyper-serotoninergic mechanisms, hypoactivity of
the hypothalamus-pituitary-adrenal axes [23] and the presence of
cytokines inammatory mediators [24]. Profound fatigue has been
reported in chronic and advanced cases of multiple sclerosis, human
immunodeciency syndrome and neurolyme, suggesting central
etiology of the syndrome. Mazzoni et al. [25] studied Parkinson’s
disease patients and demonstrated that patients with Parkinson’s
move slower than controls when moving naturally but, if encouraged,
they can execute movements at a normal speed. We contemplate
if the INCS may have a “central motor drive deciency”, as well.
Muscle spasms and tightness are frequently reported in our patient
population and in post-foodborne-botulism [20]. is is most likely
due to aection of the Renshaw neurons in the spinal cord, which
have been shown to be targeted by the toxin [26].
Muscle weakness: Is related to the direct actions of the toxin on
the neuromuscular junction. Since the junctions eects persist for 3-6
months, a true muscle weakness has a relatively short duration in these
patients with the exception of diaphragmatic and swallowing decits
when the duration is unknown. It is unclear, at present, if swallowing
and breathing problems are due to true weakness (some patients had
abnormalities in pulmonary function test) or to discoordination of
the peripheral and central neuronal pathways, or to both.
Atrophic syndrome: Weight loss associated with BoNT/A has
been demonstrated in animal studies [27]. When trophic syndromes
are present we need to consider the enormous eect of non-
neuronal Ach on the body systems. Research has demonstrated that
extraneuronal Ach is crucial for the survival and the function of the
cells: blockage of Ach receptors on non-innervated cells results in
cell dysfunction and death; adding Ach antagonists to cell cultures
induces almost immediate cell shape change with shrinkage and
cell separation; Ach regulates skin regeneration with keratocytes
containing 100 times higher Ach levels than airway cells; Ach is
crucial for almost any cell to cell contact [28]. Ach nicotinic receptors
are involved in appetite and food seeking behavior.
Autoimmune syndromes: e presence of BoNT/A blocking
antibodies in one of the cases presented here did not prohibit
the presence of good wrinkle abolishing eect suggesting that,
autoimmune mechanisms other then just the production of toxin
blocking antibodies are at play. Oshima et al. [29,30] have shown
that human lymphocytes are activated by the toxin irrespective if the
patients’ blood had or did not have blocking antibodies. is suggests
that assays of toxin blocking antibodies may not be an ecient
marker for the presence or the absence of autoimmune reaction to
the toxin. Singh et al. [31] showed that the toxin-associated proteins,
injected in the body together with BoNT/A and consisting of 2/3 of
the complex, are 5 times more immunogenic than the toxin itself.
Reports of rash or eosinophils elevation, as in the presented cases,
suggest toxin connection. e published reports of botulinum
induced autoimmune encephalitis [32] and Guillain-Barre syndrome
[33-35] indicate that BoNT/A is capable of inducing an auto-immune
reaction in humans.
Discussion of other features of INCS and hypotheses
Increased frequency of infections: Since the acetylcholinergic
pathways are involved in regulation of immunity, it is not a surprise
that this symptom is common in the patients’ population presented
here. Pneumonia was documented in animals sacriced to the toxin
[5].
Sensitivity to food and medications: Serotonin given to animals
aer BoNT/A injection increased the toxin’s activity up to 1000 times
[36]. is may explain why, almost uniformly, the cases presented
here had worsening with serotonin-reuptake inhibitors therapy.
Large amounts of sugar intake has been related to suppression of
Ach release. Only one patient was vaccinated (u shot) aer the
toxin exposure and had worsening of her symptoms, likely due to
stimulation of an already upset immune system. Note that while
steroid therapy is likely not indicated for treatment of INCS, steroids
may be useful in botulinum induced autoimmune encephalitis [32].
Crises and waxing and waning of the symptoms: e latest
research of Bomba-Warczac et al. [37] demonstrated unequivocally
that the toxin travels via retrograde axonal transport and transfers
between neurons while remaining enzymatically active. is suggests
that the occurrence of new symptoms or worsening of old symptoms
may co-inside with the time of BoNT/A transfer and engagement of
new neuronal nets. Polley et al. [38] demonstrated in animals, that 5
minutes aer intravenous injection of BoNT/A there was cessation
or signicant decrement of EEG recorded cortical activity associated
with loss of consciousness. e animals recovered in 30-60 minutes
to have another 3-4 similar episodes of EEG depression in the next
24 hours. It is dicult to explain the repetitive appearance of the
cortical depression, aer initial recovery, unless we accept the theory
that the time of appearance of cortical depression is a marker of the
time of intoxication of new neuronal nets by botulinum. Herrero et
al. [5] gave lethal dose BoNT/A to monkey, an though most of the
monkeys died shortly aer the toxin exposure, some recovered and
died 40 days later, again suggesting an existence of transneuronal
passage of the toxin, or later absorption of the toxin from peripheral
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peri-neural depots. Pharmacokinetic studies in animals suggest that
the clearance of the toxin is a signicant issue. Each biological system
has parameters of detection and operation below or above which the
data may be regarded as noise. Due to the minimal substrate cleavage
and nano-dose concentrations, the toxin seems to stay under the
radar of the elimination mechanisms of the body such as liver and
other metabolic cells [39]. It seems that BoNT/A just squats on the
inner layer of the pre-synaptic membrane of the neuron, locked into
its substrate: the synaptosomal associated protein – 25 (SNAP-25)
[40], and jamming the transmission until the neuronal membrane
is recycled, which occurs at a very slow rate. Once injected in the
muscle, only a small amount of the total toxin load is absorbed in the
neuronal terminals [39] making the rest of perineuronal-pool toxin
available for further absorption over time. Re-absorption from the
micro-compartments could be responsible for the patients’ crises
and can explain why some patients report worsening aer having
massage or aer rigorous detoxication procedures. Research has
shown that once in the neurons, BoNT/A can persist more than
one year [39], suggesting that the elimination of the toxin may take
years, as it is our experience with the cases presented here. Keller et
al. [41] showed that in spinal neuronal cultures the enzymatic activity
of BoNT/A decreased only with 50% in 78 days. is is signicant
because the toxin needs to preserve only 6% of its enzymatic activity
in order to block a synaptic transmission [40]. Since blood does not
alter the toxin at all, it has been regarded by some researchers as a
toxin holding compartment [39]. Unless methods of toxin detection
become very sensitive, readily available and frequently used, the true
duration of toxin presence in humans cannot be established. A mouse
assay was reported positive in the blood of a patient, 2 years aer
onset of her symptoms (author’s correspondence). None of the cases
cited here had mouse bioassays or other direct assays for detection of
the toxin.
Symptoms onset: It is possible that the symptoms occurring
within the rst minutes to a few hours aer the injection are due to
hematogenic spread and autonomic nerve endings blockage, while
those occurring later are due to retrograde axonal transport, which
is slower. It is unclear, at present, of how many hours are needed
for the toxin to generate axonal spread related symptoms. Moreno-
Lopez et al. showed that reduction of eld potential of cranial nerve
IV occurred 3 hours aer toxin injection in the lateral rectus muscle
of cats and that the eects were dose dependent [42].
Dose and toxin brand: e general belief in the medical
community has been that generalized BoNT/A spread may occur only
above certain toxin doses. However, we need to keep in mind that we
do not have any studies on safety of hematogenic or retrograde axonal
transport BoNT/toxicity in humans. Our data shows that spread can
occur with a dose as low as 10 units (0.08 units/kg) signifying that
likely no dose is safe when a generalized spread occurs. Matak et al.
[43] demonstrated that 3.5U/kg of BoNT/A, injected in the whisker
pad of rats, reached CNS in 72 hours and remained enzymatically
active. It is important to note that BoNT/A organ toxicity dose, which
is a dose that aects the function of the organs, is much lower then
the lethal dose (LD50) (the one that kills 50% of the injected animals).
erefore LD50 cannot be used as a safety measure for organ toxicity
and disease occurrence but can be used only to assess risk of death.
Young at al. [44] reported generalized spread symptoms in patient
case series aer a toxin dose as low as 6.8 units. Switching a patient
from one brand drug to another, as it occurred in patient #16, does
not increase safety since most drug brands contain BoNT/A. As well,
botulinum toxin types A and B carry cross reactivity, due to their
similar molecular structure.
Examination and past medical history: Almost all patients,
presented here, had a weakened immune background with presence
of past personal or family history of cancer, immune, autonomic or
allergic diseases. It is possible, that such patients’ population may be
more prone to toxin reaction, but this is to be established in the future
in larger population. A signicant nding is that only two patients
had pupillary reaction impairment (minimal one). is fact together
with the usually normal muscle power examination indicates that the
INCS diers in symptomatology from that of foodborne botulism.
Less frequent pupillary involvement has been demonstrated in
animals injected with the toxin [5].
Diagnosis and clinical markers: At present, the diagnosis is
a real challenge since there is not a high alertness in the medical
society about this signicant problem, there are no guidelines for
diagnosing iatrogenic botulinum side eects and there are no easily
available methods to prove the toxin-symptoms connection. In
foodborne botulism, the diagnosis is usually established by testing
for clostridium bacteria and toxin in food and/or stool samples. e
gold standard for testing is lethal mouse bioassay which detects the
biologically active toxin in 1-4 days. Its sensitivity of detection is 20-
30 pg/ml [45]. ELISA (Enzyme Linked Immunosorbent Assay) uses
polyclonal antibodies. e method is faster (8 hours) and its sensitivity
is 0.2 ng/ml [45]. However, it usually uses amplication methods,
which require culturing live bacteria (not present in iatrogenic cases)
to increase and detect toxin production. e same applies to the
live time PCR method which detects 5 pg/ml and uses monoclonal
antibodies [45,46]. Since it is very likely that the serum toxin levels
in INCS are much lower than that in foodborne botulism, where
bacteria are producing toxin continuously, it is possible, that we may
need more sensitive methods such as mass spectroscopy where not
only the toxin, but as well parts of the toxin can be detected. It seems
that detection of the entire toxin or the entire light chain in serum is
preferable. ere is a laboratory in Poland (Dr. Ella Kukier: ph: +48
818 89 31 93, fax: +48 81 889 33 54) which is conducting research on
mass spectroscopy methods for detecting the toxin and its particles
in human serum. e same laboratory oers lethal mouse bioassay to
the public. In the USA, the mouse assay is not available to the public
and requires approval of the state or the federal health authorities
when the diagnosis of botulism is suspected. As the Center for
Disease Control reported, in the USA, due to the nature of the toxin,
even foodborne botulism has been substantially under-diagnosed or
misdiagnosed with whole disease clusters and deaths related to the
toxin not being detected [47].
Possible, future therapies
Activated charcoal: Charcoal has been studied to have no toxicity,
even in high doses. In research, charcoal, when given trough the mouth,
enhances the elimination of multiple intravenously administered
drugs [48]. When BoNT/A was injected intraperitoneally in increasing
concentrations in two groups of mice, none of the mice in the treated
with activated charcoal group developed botulism or died, while
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all the mice in the untreated group developed botulism and died in
progressive numbers with each increment of the toxin potency. e
highest potency group, which was not exposed to charcoal, had 100%
mortality [49]. Our observation with charcoal therapy is that almost
all patients who took it had initial good eects and some alleviation
of their symptoms. Aer that the group divided in two considering
the eectiveness of the therapy: the rst group kept getting better and
improving, though at times mild crises may have occurred; the second
group had more pronounced crises of temporary worsening and the
patients stopped the therapy. However, there were two patients who
pushed through the therapy despite the temporary worsening and
had benecial results at the end. One of them, as we mentioned above,
achieved full recovery, despite that she had the worst clinical picture
from all the cases, which is an encouraging nding. is unexpected
split response prompted us to look deeper into the mechanism of the
eect of activated charcoal upon the elimination of BoNT/A from
the body. It looked like the crashes occurred more oen in patients
who took a higher dose of charcoal on a daily basis or if they had
constipation. e pharmacokinetics in animals clearly suggest that
the liver is about the only organ via which the toxin can be eliminated,
since blood leaves the toxin unchanged and the BoNT/A molecule
is too big to pass the 50 kDa size of molecule elimination-kidney
threshold [39]. is has been supported by autopsies of animals who
died from botulism where the highest accumulation of botulinum has
been found in the liver and then in the spleen [50]. We speculated that
if charcoal pools the toxin out of the tissue micro-compartment and
blood into the bowel lumen, via liver elimination while bowel motility
is slower than normal, a partial re-absorption of the toxin may occur.
is can induce secondary BoNT/A re-introduction in the blood
stream, which may present as worsening of the clinical picture. As
well, it is possible that there is a liver threshold of accumulation of
toxin before elimination. If the threshold is surpassed by pooling
more toxin from the depots to the blood than the liver can handle
at a given moment of time, the unltered amount of toxin may re-
lodge into the nerve terminals. We found that 1 capsule of 280mg
charcoal through the mouth taken every other day or twice a week
was generally safe (no crises, or very mild ones) unless the patient
had severe constipation. In our opinion, charcoal should not be used
until the constipation is resolved. e fact that the two cases whose
symptoms resolved 100% within the rst 4 months of the initial insult
aer taking charcoal early into the disease course is encouraging too.
Research has shown that Echinacea plant has some similarity to
botulinum toxin, and may compete with it [51]. Some of the reported
here patients improved while taking 400mg of Echinacea daily.
Yuliang at al. [52] suggested that the Chinese herb toosendanin
can inhibit the translocation of the light chain of the toxin. Zhou
et al. [53] stated that toosendanin has been an eective cure of
experimental botulism. e substance made synaptosomes of a rat
brain completely resistant to BoNT/A. Even aer toxin entrance into
the cells, toosendanin was still able to partially antagonize BoNT/A
substrate cleavage. e researchers concluded that the eect is likely
due to blocking the toxin approach to the substrate. Mice, which
developed botulism, cured completely in seven days aer being
treated with toosendanin. Since toosendanin has a low toxicity
prole, further research and clinical trials are highly desirable.
3-4 diamino pyridine (3-4 DAP): Is a reversible inhibitor of
voltage gated potassium channels and cholinergic agonist. Zakhari
et al. [54] demonstrated that the 3-4 DAP facilitates recovery of
post-botulinum intoxication by blocking the potassium channels
but there were some toxic eects. A less toxic cousin of 3-4 DAP,
4-aminopyridine (dalfampridine) has been available on the market
for treatment of multiple sclerosis but has never been used or studied
in BoNT/A aected patients.
Young et al. [44] reported improvement of botulinum induced
constipation with pyridostigmine.
Benadryl, which is an anti-histamine agent, has been benecial to
some of the cases presented here, likely due to eect of tuning down
the discussed above hyper histaminic state.
Boro at al. [36] showed in animals that BoNT/A activity can be
blocked by reserpine.
Tryptophan is critical for toxin activity [36], rising the question
if a tryptophan restricted diet may be benecial for some patients.
Antibodies to the toxin: (anti-toxin). Frequently asked question
by patients and physicians is if anti-toxin should be given? e present
practice guidelines allow the toxin to be given only in the rst 72
hours aer exposure, since once BoNT/A reaches the nerve terminals
the anti-toxin becomes ineective. However, the possibility of longer
lasting local toxin micro-depots presence has not been explored yet.
Suggested algorithm for safer toxin use:
1. Inform yourself, your colleagues and your patients about the
existence of the INCS and its consequences.
2. Advise the patients who develop a reaction that it is likely not
safe to continue injecting.
3. If possible, restrain from vaccinating during the period of
symptoms activity. Be aware that tetanus toxoid carries 35%
amino-acid similarity to botulinum [55].
4. Avoid giving serotonin re-uptake inhibitors and other
mediator modulating drugs or steroids since worsening may
occur.
5. Advise not to push trough fatigue, do massages or use
rigorous detoxifying methods, since crises may occur.
6. Consider skin biopsy to diagnose small ber polyneuropathy
if persistent pain and tingling are present.
7. Consider that injecting botulinum for cosmetic reasons, most
likely, does not weight against the side eect prole of the
drug.
8. Report all reactions to the toxin to e Food and Drug
Administration or its equivalents in other countries and
publish the results in peer review literature to increase
awareness.
9. Try to send serum for lethal mouse bioassay when possible
at early or later stages of the disease to establish the assay
sensitivity in such cases.
10. Know the dierence between INCS and botulinum induced
autoimmune encephalitis and polyneuropathy since there is a
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dierence in the therapy.
11. We suggest establishment of a separate reporting and
monitoring system for botulinum related side eects to
increase safety.
Conclusion
We conclude that Impaired Neuronal Communication Syndrome
(INCS) is a serious and long lasting complication to BoNT/A
therapy. e syndrome has specic features which distinguish it from
the foodborne botulism by the rare involvement of the pupillary
reaction and the rare presence of true weakness. e syndrome, as
well, diers from the autoimmune side eects to BoNT/A described
in the literature, such as autoimmune encephalitis, Guillain-
Barre syndrome and others, by having, most of the time normal
examination, laboratory results and imaging. ere is no current
wide-spread awareness of the syndrome among the medical society.
ere are no readily available markers to establish connection to the
toxin making the clinical knowledge highly important and oen the
only tool for correct diagnosis. Further research is urgently needed.
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J Bacteriol Mycol - Volume 3 Issue 4 - 2016
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