Health officials in Europe are warning of an outbreak of botulism linked to botched weight loss procedures carried out in Turkey aimed at paralyzing stomach muscles to reduce appetite. So far, authorities have identified 67 cases—53 in Turkey, 12 in Germany, and one each in Austria and Switzerland.
Botulism is a life-threatening neuroparalytic condition caused by botulinum toxin, which is produced by the bacterial species Clostridium botulinum. There are different forms of botulism, but in this outbreak, the cases are a form called iatrogenic botulism, which occurs when too much toxin is injected during medical procedures. Iatrogenic botulism is associated with generalized muscle weakness, droopy eyes, difficulty swallowing, and difficulty breathing. Outbreak cases range from mild to severe, with a number of people ending up in intensive care, the European Center for Disease Prevention and Control (ECDC) said.
Botulinum toxin is one of the most poisonous natural substances known. a dose of just 1 nanogram per kilogram of body weight is lethal. However, it has been used for cosmetic purposes, such as smoothing facial wrinkles, and some therapeutic purposes, such as treating an overactive cyst and chronic migraine headaches.
It has also been used in the stomach for weight loss purposes, although studies on this application have been mixed in terms of effectiveness. The idea is that the toxin paralyzes the stomach muscles, slowing down digestion and how quickly the stomach empties. This is intended to keep people feeling fuller for longer, leading to reduced appetite for as long as the effects of the toxin last, which can be around three months. The injection is performed using an endoscope, a tube-like device equipped with a syringe to inject the toxin directly into the stomach muscle after it is down the mouth and throat.
But things go wrong when too much botulism is injected, as seems to be the case in Turkey. Officials in Europe traced the cases in Germany, Austria and Switzerland to a single clinic in Istanbul. The cases in Turkey are also linked to this clinic, in addition to three detected in a private hospital in Izmir, Turkey. The ECDC noted that European patients coordinated their risky medical tourism through a WhatsApp group.
In the past, such clusters of iatrogenic botulism have been linked to counterfeit toxin products, as was the case in an outbreak in Egypt in 2017. Last August, the World Health Organization warned about counterfeit batches of a botulism toxin product called Dysport. The bad batches had been traced to several countries, including Turkey. However, a Turkish investigation into the current outbreak found it involved legal, licensed products, although they were not approved for stomach use, the ECDC said. Turkish authorities have reportedly suspended medical procedures at both identified health facilities and launched further investigations into the medical providers involved.
Botulism patients, meanwhile, face a long, painful road. Recovery can take weeks to months. In the 2017 outbreak linked to a counterfeit product, patients took six to 12 weeks to fully recover. Because iatrogenic botulism is relatively rare, the case fatality rate is unclear. But foodborne botulism — caused by eating improperly preserved or canned food contaminated with the toxin — has a fatality rate of between 5 and 10 percent, the ECDC noted.
Hero of antitoxins
Treatment of botulism may include mechanical ventilation in case of respiratory failure, as well as doses of an antitoxin called heptavalent botulism antitoxin (HBAT), which is made from horses. HBAT contains antibodies from horses immunized with small doses of botulinum toxin. HBAT antibodies work by binding the toxin while it is in the blood, before it irreversibly binds to presynaptic nerve endings and leads to paralysis. Therefore, the antitoxin can only prevent further paralysis. it cannot reverse any paralysis that has already occurred. However, while today’s fatality rates are lower than 10%, before the antitoxin was developed, the fatality rate was 50%, according to the US Centers for Disease Control and Prevention.
Horses are often used for such antibody-based therapies because their large body size means a large blood volume, which in turn means a large amount of antibodies—or other valuable proteins—can be collected. In the US, a thoroughbred horse named First Flight was the sole source of botulism antitoxin serum from its initial development in the 1970s until the 1990s.
First Flight was a retired racehorse who briefly worked as a kisson horse at military funerals at the Arlington National Ceremonies before allegedly hitching a ride on a general’s casket. In 1978, at the age of 10, he was transferred to the US Army Medical Research Institute of Infectious Diseases at Fort Detrick, Maryland, where he became the nation’s only living plant for botulism antitoxin, while building a reputation for his jovial personality. After donating nearly 16,000 liters of blood during the 1980s and 1990s, First Flight retired. He died in his paddock at Fort Detrick of natural causes at the ripe old age of 31. His halter and lead are kept at the Smithsonian National Museum of American History.