1309 - A Rare Complication in Cancer Rehabilitation: Erysipelas Following Botulinum Toxin Injection for Radiation-Induced Trismus

Thursday, February 19, 2026

5:00 PM - 6:30 PM AST

Presenting Author(s)

MP

Marian Pedreira, BS

OMS-4
Edward Via College of Osteopathic Medicine, Virginia Campus
Blacksburg, Virginia, United States

Co-Author(s)

EB

Elizabeth Bautista-Whitaker, DO

PGY-3
Carolinas Rehabilitation
Charlotte, North Carolina, United States
TP

Terrence Pugh, MD

Associate Professor, Medical Director, Director of Cancer Rehabilitation
Carolinas Rehabilitation
Charlotte, North Carolina, United States

Submitter(s)

MP

Marian Pedreira

VCOM Virginia
Abingdon, Virginia, United States

Case Diagnosis: Erysipelas following Botulinum Toxin Injection for Radiation-Induced Trismus.

Case Description: A 76-year-old male presents to the emergency department with facial swelling, neuropathic pain, orbital and intranasal erythema one day after receiving bilateral masseter IncobotulinumtoxinA 100U injection. His history includes squamous cell carcinoma of the tongue base, chemotherapy-induced peripheral neuropathy, radiation-induced trismus, and monoclonal gammopathy of undetermined significance (MGUS). The patient previously tolerated botulinum injections for trismus without complications. He was diagnosed with erysipelas and treated with IV antibiotics and prednisone, then discharged on oral antibiotics. CT Head and facial bones were negative for other etiologies of facial swelling; and CBC revealed a normal WBC. He returned the following day with respiratory distress due to throat swelling, 48 hours post-injection, with definitive treatment requiring IV steroids and an extended course of antibiotics for complete resolution of facial swelling.

Discussions: Erysipelas, an acute bacterial skin infection with well-demarcated erythema and systemic symptoms, is not reported as a complication of botulinum toxin in FDA safety data and post-marketing surveillance. Tertiary cancer center retrospective reviews report an infection-related adverse event rate of 7% in patients who received botulinum toxin, though erysipelas is not documented. Chemotherapy-induced neuropathy may alter immune response and skin integrity, increasing susceptibility to infection. This patient’s multiple anaphylactic drug allergies to atenolol, atorvastatin, animal products, and contrast media suggest an underlying atopic state and heightened hypersensitivity. Additionally, MGUS confers a 2-fold increased risk of bacterial and viral infections, potentially predisposing him to erysipelas.

Conclusions: Erysipelas is a rare but serious adverse event following botulinum toxin injection. Prompt recognition and treatment are critical, particularly in patients with cancer-related immunocompromise, MGUS, or hypersensitivity. Physiatrists administering botulinum toxin for trismus or spasticity in cancer rehabilitation should exercise caution towards infection risk. Careful monitoring and patient education are crucial, as even previously well-tolerated injections may lead to unexpected complications.