Notes From the Field: Severe Illnesses After Self-Injection of Botulinum Toxin Purchased Online — New York, Texas, and Wisconsin, 2025

Investigation and Outcomes

Patients Reported to CDC

During May–June 2025, three women aged 29, 50, and 59 years (one each from New York, Texas, and Wisconsin, respectively) self-injected BoNT and subsequently experienced severe illness (Table). One patient injected BoNT into her face, one into her neck, and the third into her neck and face. Reported total units that were self-administered ranged from 11 to approximately 200. None of the patients was reported to have a health care license, be a professional injector, or otherwise have the training and credentials required to purchase or inject BoNT; no link was reported among the patients. CDC was notified about the patients by their respective jurisdictional health departments.

Clinical Complications and Course of Illness

Illness onset occurred 3–5 days after injection and included dysphagia, dysarthria, diplopia, ptosis, respiratory difficulties, upper extremity weakness, and other signs and symptoms (Table). Each patient was evaluated in an emergency department because of symptom progression. All three were hospitalized (with length of hospitalization ranging from 3 to 6 days). One patient required invasive mechanical ventilation because of airway concerns. After the clinical teams for the three patients learned about the history of BoNT self-injection from their patients, all suspected botulism. They coordinated with their respective jurisdictional health departments to contact CDC’s clinical botulism service about the potential use of botulism antitoxin (BAT), an equine-derived preparation of antibodies that bind to and neutralize BoNT in the bloodstream that has not yet irreversibly bound to synaptic receptors to prevent progression of paralysis and consequent complications (2).

Consultation with CDC and Release of Botulism Antitoxin

Following these separate consultations, each clinical team requested heptavalent BAT, which was released by CDC.^§ Before administration, a blood specimen was collected from each patient and shipped to public health laboratories to test for the presence of BoNT. Per CDC botulism clinical guidelines, BAT treatment was initiated based on clinician suspicion of botulism, before BoNT testing results were available (2). BAT was administered to each patient 3–4 days after symptom onset. All patients were discharged from the hospital with varying degrees of residual morbidity. BoNT testing results were available after discharge; circulating BoNT was not detected in the serum of any of the three patients.

Efforts to Identify Source of BoNT

Health department staff members attempted to identify the source of the products. Patients provided limited product information and reported that the products were purchased online from sources outside the United States. Some patients communicated with vendors via messaging platforms such as WhatsApp. None provided direct online links to the products or vendors, and health departments were unable to obtain any of the products for testing. One patient noted using the internet to research injection techniques for specific anatomic sites. Additional follow-up to identify product vendors was unsuccessful.

Preliminary Conclusions and Actions

Licensed medical providers have safely administered FDA-approved BoNT for decades, despite its being one of the most potent naturally occurring toxins (2,3). However, unsafe use (e.g., use of counterfeit products, administration by unlicensed providers, or self-injection) has resulted in severe illnesses, with some patients requiring invasive mechanical ventilation and administration of BAT; no deaths have been reported (CDC, unpublished data, 2025). Health care providers should counsel persons interested in BoNT injections about risks associated with improper administration and encourage them to seek injections only from licensed, trained medical professionals operating in accordance with jurisdictional requirements and using FDA-approved BoNT. Misleading and inappropriate guidance from social media regarding self-injection of BoNT should be countered with information about the associated risks.

The illnesses described in this report are consistent with local and possible remote anatomic spread of BoNT, similar to previously reported cases that occurred after cosmetic injections of counterfeit or presumed counterfeit BoNT products (4). BoNT was not detected in the serum of any of the three patients, a common finding in all types of botulism (2). Possible reasons BoNT was not detected in these patients include 1) BoNT did not circulate in these patients’ bloodstreams, and their clinical features were the result of diffusion, rather than circulatory dissemination, of BoNT from where it was injected to nearby muscles; 2) BoNT was circulating in the patients’ bloodstream when the specimens were obtained but at levels below the assay detection threshold; or 3) BoNT that previously circulated in the patients’ bloodstream had already bound to synaptic receptors when the specimens were obtained. The 3-day to 4-day delay between symptom onset and collection of serum specimens could have precluded detection of BoNT that had previously been present. BoNT has been detected rarely in serum after cosmetic or therapeutic injection, with fewer than 10 such cases identified in the United States (CDC, unpublished data, 2025). It is unclear how beneficial BAT administration was in these three patients because there was no detectable BoNT for the BAT to bind to at the time of administration. The limited information provided by the patients about the products they used suggests that none were FDA-approved products; notably, all three patients reported purchasing BoNT online from vendors in Asia.

Medications, including BoNT, that are purchased from unlicensed sources such as online retailers might be misbranded, mislabeled or unlabeled, adulterated, counterfeit, contaminated, improperly stored or transported, ineffective, or unsafe^¶ (5). Persons without a health care license should not purchase BoNT online and should only receive injections from a provider authorized to purchase and administer BoNT in their state. Although requirements for BoNT injection vary by state, patients can check with their local licensing boards or locate authorized providers through provider lookup tools available on FDA-approved BoNT product or professional organization websites. Health care providers should avoid purchasing BoNT from unlicensed sources. Warning signs that online pharmacies might be selling unsafe products include having an address outside the United States or selling damaged, mislabeled, expired, or deeply discounted products (FDA | Considering an Online Pharmacy?).

CDC offers a clinical botulism service (telephone: 770-488-7100) 24 hours a day to provide information for health care providers and health departments about diagnosing botulism and using BAT. FDA’s MedWatch program is available for reporting adverse effects from BoNT products, as well as possible counterfeit BoNT products (FDA | MedWatch Online Voluntary Reporting Form 3500).