Botulinum neurotoxins: genetic, structural and mechanistic insights

Effects of botulinum neurotoxin-associated proteins on cellular organelle dynamics in NRK-52E cells

Clostridium botulinum produces seven distinct serotypes (A-G) of botulinum neurotoxin (BoNT), a potent biological toxin that affects the nervous system. In its natural state, BoNT forms a progenitor toxin complex with neurotoxin-associated proteins (NAPs), substantially enhancing its stability and oral toxicity. Recent studies have shown that NAPs in certain serotypes induce vacuolation and death in various epithelial cell types. In this study, we examined the effects of the serotype D NAPs complex (NAPs/D) on intracellular organelles in NRK-52E cells, a rat kidney cell line. NRK-52E cells were selected because they exhibit a unique response, showing vacuolation without undergoing cell death upon exposure to NAPs/D. Our findings indicated that NAPs/D-induced vacuole formation was associated with the reduced size of the Golgi apparatus. Additionally, vacuoles were associated with endocytic vesicles, implying that NAPs/D modulate endocytic pathways and affect intracellular transport. Furthermore, NAPs/D exposure activated early autophagic signaling, as evidenced by increased LC3 expression, although vacuole formation appeared to occur independently of the complete autophagy process. These findings provide valuable insights into the cellular mechanisms underlying BoNT toxicity and highlight the complex interplay between NAPs/D-induced vacuolation, endocytosis, and autophagy. This study highlights potential therapeutic approaches to mitigate the effects of botulism by targeting these pathways.

Advancements in the application of botulinum toxin type a in the treatment of anorectal disorders

Botulinum toxin type A (BoNT/A) has garnered significant attention in recent years due to its unique biological properties and neuromuscular blocking effects, particularly in the field of anorectal disorders. This review discusses the application of BoNT/A in treating various conditions such as anal sphincter spasms, hemorrhoids, anal fissures, and other related ailments. We analyze the latest research findings regarding its efficacy, safety, and clinical applications, highlighting both the current state of research and the challenges that persist in this area. This synthesis aims to provide valuable insights and guidance for future studies and clinical practices involving BoNT/A in the management of anorectal diseases.

Widespread occurrence of botulinum and tetanus neurotoxin genes in ancient DNA

BACKGROUND

Ancient DNA collected from archaeological specimens not only provides a window into ancient human genetic diversity but also contains a rich mixture of associated microbial DNA including potential pathogens. In recent work, we identified C. tetani and tetanus neurotoxin (TeNT) genes in ancient DNA datasets collected from human archaeological specimens. However, the reasons underlying the occurrence of these toxin genes and the extent to which other toxin genes are present in ancient DNA is unclear.

METHODS

Here, we performed a large-scale analysis of 6435 ancient DNA (aDNA) sequencing datasets including human and non-human sources, searching for 49 clostridial neurotoxin types and subtypes, and 3 additional unrelated toxins.

RESULTS

Our search identified a total of 105 ancient DNA datasets (1.6 %) containing significant matches to one or more neurotoxin genes. Consistent with our earlier work, TeNT genes were most common, found in 50 ancient DNA datasets. In addition, we identified sequences encoding diverse botulinum neurotoxins including BoNT/C (40 samples), BoNT/D (6 samples), BoNT/B (4 samples), BoNT/E (1 sample), and the Enterococcus-associated BoNT/En (10 samples). TeNT genes were detected in a broad range of ancient samples including human and animal (horse, wild bear, chimpanzee, gorilla, dog) remains, whereas the largest diversity of toxins was detected in aDNA from Egyptian mummies. Phylogenetic and sequence analysis of the identified matches revealed close identity to modern forms of these toxins. Damage analysis revealed several toxin genes with hallmarks of ancient DNA associated damage, indicative of an ancient origin.

CONCLUSIONS

Our work reveals that clostridial neurotoxin genes occur frequently in aDNA samples, including human and animal-associated toxin variants. We conclude that the frequent association of these genes with aDNA likely reflects a strong ecological association of pathogenic clostridia with decaying human and animal remains and possible post-mortem colonization of these samples.

Botulinum neurotoxins exploit host digestive proteases to boost their oral toxicity via activating OrfXs/P47

Botulinum neurotoxins (BoNTs) rank among the most potent toxins and many of them are produced by bacteria carrying the orfX gene cluster that also encodes four nontoxic proteins (OrfX1, OrfX2, OrfX3 and P47). The orfX gene cluster is also found in the genomes of many non-BoNT-producing bacteria, often alongside genes encoding oral insecticidal toxins. However, the functions of these OrfXs and P47 remain elusive. Here, we demonstrate that the combined action of all four components (OrfXs and P47) drastically boosts the oral toxicity of BoNT in mice, following proteolytic activation by digestive proteases that oral toxins regularly confront. In particular, OrfX2 adopts a self-inhibiting state, engaging with BoNT through another clostridial protein, nontoxic non-hemagglutinin (NTNH), only after proteolytic activation. Cryo-electron microscopy studies unveil that two molecules of protease-activated OrfX2 simultaneously associate with NTNH, a binding mode crucial for boosting BoNT oral toxicity. Collectively, these studies offer novel insights into the physiological functions and regulatory mechanisms of OrfXs and P47 of BoNTs, shedding light on the pathogenesis of other bacterial toxins associated with homologous OrfXs and P47.

Turbinate Injection of Botulinum Toxin in the Treatment of the Chronic Rhinitis

OBJECTIVES

This systemic review with meta-analysis evaluated the effect of intranasal BTX-A turbinate injection on chronic rhinitis-related symptoms.

DATA SOURCES

PubMed, SCOPUS, Embase, Web of Science, and Cochrane databases.

REVIEW METHODS

We reviewed studies retrieved from databases up to Aug 2024. The studies evaluating the degree of change of rhinitis-related symptom scores and quality of life before and after BTX-A injection were analyzed. Standard mean differences were used to calculate effect sizes.

RESULTS

A total of 269 patients from 7 studies were analyzed. BTX-A injection showed a significant improvement in rhinitis-related symptoms (congestion: 2.5416, 95% CI 1.0927-3.9905, I2 = 94.4%, itching: 1.2553, 95% CI 0.6660-1.8446; I2 = 70.8%, rhinorrhea: 1.8451, 95% CI 1.0468-2.6435, I2 = 89.7%, and sneezing: 1.3580, 95% CI 0.5194-2.1967; I2 = 90.7%), total nasal symptom score (2.4020, 95% CI 1.4161-3.3879, I2 = 86.1%), and quality of life (1.5256, 95% CI 1.0760-1.9752; I2 = 0.0%) throughout the follow-up period (4 months). However, 3 months after injection, although symptom improvement remained, there was no statistical significance. Allergic rhinitis (AR) patients showed a significant improvement in rhinitis-related symptoms compared with nonallergic rhinitis (NAR) patients.

CONCLUSIONS

Nasal symptoms and quality of life scores related to rhinitis were decreased after BTX-A injection. In particular, this treatment showed better efficacy in AR and could be more beneficial for the symptoms of nasal congestion and rhinorrhea at the early periods of treatment. However, the effects lasted for a relatively short period of only 2-3 months. Laryngoscope, 135:1545-1552, 2025.

Bifunctional Inhibition of Botulinum Neurotoxin A Protease: Unexpected Active Site Inhibition Enhances Covalent Targeting of an Allosteric Site

Botulinum neurotoxin (BoNT) is the most toxic protein known to man and a Tier 1 bioterrorism agent. Among its serotypes, BoNT/A possesses the greatest potency and persistence, as such strategies to counteract it are highly coveted. Bifunctional molecules incorporating both metal chelation and a covalent warhead have shown great potential for blunting BoNT/A LC's toxicity/longevity. To further explore this idea, new warheads as well as zinc metal-chelating scaffolds were prepared and examined. The structure-activity relationship and kinetic analyses of these inhibitors challenged the standard protease assay leading to a new screening platform implemented and validated. Reconnaissance studies from this new screening platform delineated an unprecedented structural flexibility associated with BoNT/A's enzyme pocket, which can be induced by a small molecule for enhanced allosteric target inhibition of the protease. The culmination of these findings offers previously unrealized opportunities for neutralizing the BoNT/A protease and thus future in vivo applications.

Botulism in the Highlands: Understanding the High-Altitude Effect

Botulism is a foodborne, life-threatening neuroparalytic disease caused by Clostridium botulinum, an anaerobic, gram-positive, spore-forming bacteria. Its incidence is unknown and underestimated due to missed diagnoses, especially in remote areas. It is divided into four main clinical types: Infant, adult-onset foodborne, iatrogenic, and wound botulism. The overall goal of the article is to focus on the geographic differences in incidence, including its propensity to high-altitude areas, and shed light on the theories behind this propensity.

Botulinum Toxin Therapy: A Comprehensive Review on Clinical and Pharmacological Insights

Background: Botulinum toxin (BoNT), produced by Clostridium botulinum, has transitioned from being a lethal neurotoxin to a versatile therapeutic agent. Its ability to inhibit neurotransmitter release by targeting Soluble N-ethylmaleimide-sensitive factor Attachment Protein Receptor (SNARE) proteins underpins its applications in treating conditions such as spasticity, dystonia, chronic pain, and overactive bladder. The clinical and pharmacological properties of BoNT have been extensively studied, with significant advancements in its therapeutic use, safety profile, and understanding of associated adverse effects. Objective: This comprehensive review aims to consolidate historical developments, molecular mechanisms, clinical applications, and challenges associated with BoNT, with a focus on expanding its therapeutic scope while ensuring safety and efficacy. Method: A narrative approach was used to analyze and synthesize insights from 155 references spanning experimental studies, clinical trials, and reviews. Key topics included BoNT's historical milestones, mechanisms of action, therapeutic applications, and adverse events. Findings: BoNT demonstrates remarkable efficacy in a wide range of medical and cosmetic applications. In movement disorders such as dystonia and spasticity, it reduces muscle overactivity and improves functional outcomes. In chronic pain management, including migraines and neuropathic pain, BoNT significantly alleviates symptoms by modulating neurotransmitter activity. Cosmetic use for conditions like glabellar lines and hyperhidrosis highlights its precision and safety when administered appropriately. For conditions like strabismus and blepharospasm, BoNT effectively restores muscle control, reducing involuntary contractions. In urological applications, BoNT has proven to be an effective therapy for overactive bladder, offering significant symptom relief in refractory cases. However, concerns about long-distance effects, where the toxin may spread beyond the injection site to affect distant muscles or systems, have been reported in certain high-dose or sensitive populations. These findings emphasize the importance of dose optimization and patient-specific approaches. Adverse effects such as localized pain, hematoma, dysphagia, and systemic effects, particularly in high-risk groups, underscore the need for careful monitoring. The development of immunogenicity, leading to neutralizing antibodies, remains a challenge that impacts long-term therapeutic efficacy. Emerging research on novel serotypes, including BoNT/X, and innovations in delivery mechanisms, offer promising avenues to address current limitations. Advances in optimizing dosing regimens and refining injection techniques have also contributed to minimizing complications and improving outcomes across diverse patient populations. Conclusions: BoNT remains a cornerstone in neurology and cosmetic medicine, with its therapeutic potential still expanding. The balance between efficacy and safety, driven by innovations in formulation and application, underscores the importance of continued research. Future directions should focus on minimizing adverse effects, reducing immunogenicity, and exploring novel indications to further enhance its clinical utility.

An Effective Prophylactic and Therapeutic Protection Against Botulinum Type A Intoxication in Mice and Rabbits Using a Humanized Monoclonal Antibody

Botulinum neurotoxins (BoNTs) are the most potent toxins on Earth and are classified as Category A biological agents. BoNTs lead to paralysis in humans and cause botulism. Antibody therapeutics can effectively treat toxin-mediated infectious diseases. In this study, we generated a pharmaceutical humanized monoclonal antibody (HZ45 mAb) to prevent or treat botulism. HZ45 binds to the heavy chain receptor (HCR) domain of the toxin, preventing the toxin from entering the cell. The mAb was produced using hybridoma technology and phage display. We evaluated HZ45 mAb for the neutralization of BoNT serotype A (BoNT/A) in mice and rabbits. The survival results showed that pretreatment with HZ45 mAb provided 100% protection at a dose of 0.1 mg per mouse against a maximum of 100 LD50 of BoNT/A. To assess the therapeutic efficacy of HZ45 mAb in New Zealand white rabbits (NZWs), a 5 mg dose was administered 4 or 8 h after challenge with 10 LD50. The results indicated that 5 mg of HZ45 could treat the NZWs within 8 h after exposure to 10 LD50 botulinum. Consequently, in an in vivo context, including mice and rabbits, HZ45 mAb could protect against botulinum type A intoxication.

SiO2/Si interferometers designed for on-site botulinum neurotoxin serotypes B and C quantification and biological activity assessment

Botulinum neurotoxins (BoNT), the agent causing botulism, exhibit the highest potency among bacterial toxins and pose a significant threat to both humans and animals. The current in vivo method (mouse lethality assay, MLA) is inappropriate for real-time and pen-side assessment of the occurring outbreak or case. Herein, we describe a reflective-based biosensor capable of detecting the toxin's type and activity state by competitive immunoassay and endopeptidase activity, respectively. Two serotypes (BoNT-B and BoNT-C) were assessed independently by SiO2/Si interferometers using simulating antigens or specific peptides (i.e., synaptosomal-associated protein and vesicle-associated membrane protein). The reflective responses of both platforms were biochemically amplified using 4-chloro-1-naphthol oxidation into insoluble products. The resulting refractive index variations were observed in real-time using reflective interferometric Fourier transform spectroscopy. The portable bioassay depicted high sensitivity, selectivity, and near real-time rapid assessment (0.14 and 0.47 pg mL-1 for BoNT-C and BoNT-B, negligible interferences with interfering serotypes, respectively). Additionally, the applicability of the bioassay for monitoring extracted toxins was tested against the in vivo method with satisfactory performance values. Overall, the presented approach can improve field assessment of new botulism incidences by acquiring epidemiological data in near real-time, thus eliminating the need for the MLA approach.

Advancements in the management of overactive bladder in women using nano-botulinum toxin type A: A narrative review

Intravesical injections of botulinum toxin type A (BTX-A) are effective for treating refractory overactive bladder (OAB) in women. However, the adverse effects linked to the injections, such as hematuria, pain, and infection, and need for repeated injections can lower patient compliance and make the treatment inconvenient. Hence, urologists are actively pursuing less invasive and more convenient methods for the intravesical delivery of BTX-A. Advances in nanotechnology have facilitated noninvasive intravesical drug delivery. Currently, liposomes, hydrogels, nanoparticles, and many other forms of carriers can be used to enhance bladder wall permeability. This facilitates the entry of BTX-A into the bladder wall, allowing it to exert its effects. In this review, the feasibility and efficacy of liposomes, thermosensitive hydrogels, and hyaluronic acid-phosphatidylethanolamine for the treatment of OAB in women are discussed along with recent animal experiments on the use of nanotechnology-delivered BTX-A for the treatment of OAB in female rat models. Although the clinical efficacy of nanocarrier-encapsulated BTX-A for the treatment of OAB in women has not yet matched that of direct urethral muscle injection of BTX-A, improvements in certain symptoms indicate the potential of bladder instillation of nanocarrier-encapsulated BTX-A for future clinical applications. Consequently, further research on nanomaterials is warranted to advance the development of nanocarriers for the noninvasive delivery of BTX-A in the bladder.

The Role of Botulinum Toxin for Masseter Muscle Hypertrophy: A Comprehensive Review

Masticatory muscle hypertrophy (MMH) is a rare clinical phenomenon of uncertain etiology, characterized by a soft swelling near the angle of the jaw. This abnormal enlargement of the masseter muscle can alter the facial profile, leading to aesthetic concerns. Moreover, MMH may also have significant functional repercussions, including pain in the masseter region, often associated with temporomandibular disorders, fatigue, and discomfort during mastication. Non-conservative approaches offer an effective and minimally invasive solution by inducing localized muscle relaxation and reducing hypertrophy. Botulinum neurotoxin type A (BoNT/A) represents a therapeutic option for managing MMH, considering that injections can effectively reduce the masseter muscle volume, improving both facial aesthetics and related symptoms. Currently, the standard non-surgical management of MMH is BoNT/A injections, although consensus on the average dosage has not been definitely reached; on the other hand, there are data available in the literature about the injection technique of BoNT/A for lower face contouring. Therefore, the present comprehensive review aimed at exploring in detail the role of BoNT/A in the treatment of masseter muscle hypertrophy, describing its mechanism of action, the administration protocols, the clinical effects, and any side effects.

Cryo-EM structure of the botulinum neurotoxin A/SV2B complex and its implications for translocation

Botulinum neurotoxin A1 (BoNT/A1) belongs to the most potent toxins and is used as a major therapeutic agent. Neurotoxin conformation is crucial for its translocation to the neuronal cytosol, a key process for intoxication that is only poorly understood. To gain molecular insights into the steps preceding toxin translocation, we determine cryo-EM structures of BoNT/A1 alone and in complex with its receptor synaptic vesicle glycoprotein 2B (SV2B). In solution, BoNT/A1 adopts a unique, semi-closed conformation. The toxin changes its structure into an open state upon receptor binding with the translocation domain (HN) and the catalytic domain (LC) remote from the membrane, suggesting translocation incompatibility. Under acidic pH conditions, where translocation is initiated, receptor-bound BoNT/A1 switches back into a semi-closed conformation. This conformation brings the LC and HN close to the membrane, suggesting that a translocation-competent state of the toxin is required for successful LC transport into the neuronal cytosol.

Botulinum Neurotoxins as Two-Faced Janus Proteins

Botulinum neurotoxins are synthetized by anaerobic, spore-forming bacteria that inhibit acetylcholine release at the level of the neuromuscular and autonomic cholinergic junctions, thus inducing a series of symptoms, the most relevant of which is flaccid paralysis. At least seven serotypes and over 40 subtypes are known, and they are among the most poisonous natural substances. There are different forms of botulism according to the route of contamination, but the clinical manifestation of descending symmetric flaccid paralysis is consistent, regardless of the route of contamination. It is very severe and potentially lethal. The induced paralysis lasts as long as the toxin is active, with variable length, according to the serotype of the toxin. This transient activity, as well as the precise mechanism of action, are the basis for the rationale behind use of the toxin in therapy for several clinical conditions, particularly, spastic conditions, as well as chronic migraine and axillary hyperhidrosis. The toxin has also been approved for the reduction in facial wrinkles; all these clinical applications, coupled with the toxin's risks, have earned botulinum the title of a two-faced Janus protein. No approved vaccines are currently available, andthe only approved antidotes are the human specific intravenous immunoglobulins for infant botulism and the heptavalent equine immunoglobulins/(F(ab')2 for adults. Nanobodies, which show great promise, may penetrate neuronal cells to inactivate the toxin within the cytoplasm, and Ebselen, a non-toxic, economic, small-molecule inhibitor, has the characteristic of inhibiting the toxin irrespective of the serotype.

Recombinant expression of receptor binding domains of all eight subtypes of botulinum neurotoxin type A for generation of antitoxins with broad reactivity

Background

Botulinum neurotoxin type A (BoNT/A) represents a major threat to global public health because of its most potent toxicity with the longest persistence. Several camelid single-domain antibodies (or VHHs) have been reported to exhibit high neutralizing activity against the receptor binding domain (H C) of the BoNT/A subtype used to generate them. However, it remains unclear if these VHHs can neutralize effectively H C of other BoNT/A subtypes. This study aimed to generate H C domains of all eight BoNT/A subtypes and to screen for VHHs with broad reactivity against these domains.

Methods

H C domains of BoNT/A1-A8 were recombinantly produced in Escherichia coli. The bont/H CA1 fragment was amplified from sludge sample and cloned into pET45b vector by Gibson assembly. Expression vectors for H C domains of BoNT/A2-A8 were derived from pET45b-H CA1 by site-directed mutagenesis and/or in-house gene synthesis. Similarly, VHHs were synthesized and cloned into pET22b vector. Recombinant protein were purified by Ni-NTA spin columns and analyzed by SDS-PAGE. ELISA was used to confirm the antigenicity of H C domains and to evaluate the reactivity of VHHs to these domains.

Results

SDS-PAGE analysis and ELISA results with commercial polyclonal antibody demonstrated the H C domains of all eight BoNT/A subtypes were correctly produced. ELISA results using a VHH panel indicated that, apart from ciA-C2, a well-characterized VHH specific for H C of BoNT/A1, two new VHHs were found to recognize the H C domains of all BoNT/A subtypes, of which VHH-A3 displayed EC 50 values for these domains close to those of ciA-C2.

Conclusion

This study provided a resource to comprehensively identify antitoxins conferring broad protection against BoNT/A.

The Effect of Anti-Activin Receptor Type IIA and Type IIB Antibody on Muscle, Bone and Blood in Healthy and Osteosarcopenic Mice

BACKGROUND

Anti-Activin Receptor Type IIA and Type IIB antibody (αActRIIA/IIB ab) is a recently developed drug class that targets the activin receptor signalling pathway. Inhibition of receptor ligands (activins, myostatin, growth differentiation factor 11, etc.) can lead to skeletal muscle hypertrophy, bone formation, and increased haematopoiesis. Despite the αActRIIA/IIB ab, bimagrumab, having progressed to clinical trials, two crucial questions about αActRIIA/IIB ab therapy remain: Does αActRIIA/IIB ab influence bone metabolism and bone strength similarly to its generic classmates (activin receptor-based ligand traps)? Does αActRIIA/IIB ab affect red blood cell parameters, thereby increasing the risk of thromboembolism, similar to its generic classmates? Therefore, the aim of the present study was to investigate the therapeutic potential of αActRIIA/IIB ab in a mouse model of concurrent sarcopenia and osteopenia and to investigate the effect on bone and haematopoiesis in more detail.

METHODS

In C57BL/6JRj mice, combined sarcopenia and osteopenia were induced locally by injecting botulinum toxin A into the right hindlimb, resulting in acute muscle paresis. Immediately after immobilization, mice received twice-weekly intraperitoneal injections with αActRIIA/IIB ab (10 mg/kg) for 21 days, after which they were sacrificed. Muscle mass, skeletal muscle fibre size and Smad2 expression were analysed in the rectus femoris and gastrocnemius muscles. Bone mass and bone microstructure were analysed in the trabecular bone at the distal femoral metaphysis, while the cortical bone was analysed at the femoral mid-diaphysis. In a substudy, the effect on haematopoiesis was explored 2 and 7 days after a single αActRIIA/IIB ab (30 mg/kg) injection in C57BL/6JRj mice.

RESULTS

αActRIIA/IIB ab caused a large increase in muscle mass in both healthy (+21%) and immobilized (sarcopenic and osteopenic) (+12%) mice. Furthermore, αActRIIA/IIB ab increased trabecular bone (bone volume fraction) for both healthy (+65%) and immobilized (+44%) mice. For cortical bone, αActRIIA/IIB ab caused a small, but significant, increase in bone area (+6%) for immobilized mice, but not for healthy mice. Treatment with αActRIIA/IIB ab did not change red blood cell count, haemoglobin concentration or mean cell volume after either 2 or 7 days.

CONCLUSIONS

Treatment with αActRIIA/IIB ab caused a significant increase in both skeletal muscle mass and bone parameters in both healthy and immobilized mice, suggesting a potential in the treatment of concurrent osteopenia and sarcopenia. Interestingly, the bone anabolic effect of the treatment was much more pronounced on trabecular bone than on cortical bone. There was no pronounced effect of short-term treatment on haematopoiesis.

Excitation-contraction coupling inhibitors potentiate the actions of botulinum neurotoxin type A at the neuromuscular junction

BACKGROUND AND PURPOSE

Botulinum neurotoxin type A1 (BoNT/A) is one of the most potent neurotoxins known. At the same time, it is also one of the safest therapeutic agents used for the treatment of several human disorders and in aesthetic medicine. Notwithstanding great effectiveness, strategies to accelerate the onset and prolong BoNT/A action would significantly ameliorate its pharmacological effects with beneficial outcomes for clinical use.

EXPERIMENTAL APPROACH

Here, we combined BoNT/A with two fast-acting inhibitors of excitation-contraction coupling inhibitors (ECCI), either the μ-conotoxin CnIIIC or dantrolene, and tested the effect of their co-injection on a model of hind-limb paralysis in rodents using behavioural, biochemical, imaging and electrophysiological assays.

KEY RESULTS

The BoNT/A-ECCI combinations accelerated the onset of muscle relaxation. Surprisingly, they also potentiated the peak effect and extended the duration of the three BoNT/A commercial preparations OnabotulinumtoxinA, AbobotulinumtoxinA and IncobotulinumtoxinA. ECCI co-injection increased the number of BoNT/A molecules entering motoneuron terminals, which induced a faster and greater cleavage of SNAP-25 during the onset and peak phases, and prolonged the attenuation of nerve-muscle neurotransmission during the recovery phase. We estimate that ECCI co-injection yields a threefold potentiation in BoNT/A pharmacological activity.

CONCLUSIONS AND IMPLICATIONS

Overall, our results show that the pharmacological activity of BoNT/A can be combined and synergized with other bioactive molecules and uncover a novel strategy to enhance the neuromuscular effects of BoNT/A without altering the neurotoxin moiety or intrinsic activity, thus maintaining its exceptional safety profile.

Combination of Pretarsal and Preseptal Botulinum Toxin Injections in the Treatment of Blepharospasm: A Prospective Nonrandomized Clinical Trial

PURPOSE

To compare the efficacy of two botulinum toxin (BoNT) injection methods, pretarsal (PT) combined with preseptal (PS) injection (PT-PS) and conventional PT injection, in the treatment of benign essential blepharospasm (BEB).

DESIGN

Prospective nonrandomized clinical trial.

METHODS

From January 2023 to April 2024, 95 BoNT injections into orbicularis oculi were performed in 45 BEB patients, including 52 PT-PS injections s and 43 PT injections. Jankovic Rating Scale (JRS) and Blepharospasm Disability Index (BSDI) were used to assess motor symptoms. The efficacy of two injection methods for BEB was compared in terms of latency to response (LTR), latency to the peak response (LPR), duration of peak response (DPR), duration of response (DOR), satisfaction degree, and possible complications.

RESULTS

Both injection methods significantly improved JRS and BSDI scores in patients with BEB. However, PT-PS injections showed a shorter LTR ([4.00 (3.00, 6.00] vs 5.00 [4.00, 7.00] days, P = .024) and LPR (23.50 [16.00, 26.00] vs 26.00 [20.00, 30.00] days, P = .040), a longer DPR (88.00 [80.50, 104.75] vs 75.00 [65.00, 92.00] days, P = .003) and DOR (135.00 [118.50, 153.75] vs 121.00 [107.00, 135.00] days, P = .003) than PT injections. Patients with PT-PS injections were more satisfied than those with PT injections (9.50 [8.50, 10.00] vs 8.00 [7.50, 9.00], P < .001), and around 2/3 of patients were more willing to receive the combined injection method later. Among patients receiving PT-PS injections, only one case experienced ptosis, and there were no significant differences in other complications such as lacrimation, dry eyes, and blurred vision between the two injection methods.

CONCLUSIONS

PT-PS injections of BoNT showed more advantages in the treatment of BEB than PT injections in terms of both their efficacy and patients' satisfactions.

Probing the properties of PTEN specific botulinum toxin type E mutants

Botulinum neurotoxins (BoNT) are established biopharmaceuticals for neuromuscular and secretory conditions based on their ability to block neurotransmitter release from neurons by proteolyzing specific soluble N-ethylmaleimide-sensitive factor attachment protein receptor (SNARE) proteins. Recently, a mutant catalytic domain of serotype E (LC/E) exhibiting 16 mutations was reported to cleave the phosphatase and tensin homolog (PTEN). This molecule represents an attractive new target in neurons as several reports support PTEN knockdown as a strategy to stimulate axonal regeneration after injury. Though this LC/E mutant was shown to cleave PTEN in primary neurons through lentivirus-based expression, its expression and functionality as mutated full-length BoNT/E have not been studied. Hence, we assembled the 16 mutations stepwise in a bacterial expression plasmid for LC/E and purified several multiple mutants of LC/E. Biochemical characterization showed that the 16-fold mutant did not exhibit a detectable activity toward SNAP-25 up to 10 µM final concentration while it displayed an EC50 of approximately 200 nM for PTEN, exceeding 1000-fold that for LC/E-wt on the native substrate SNAP-25. Unexpectedly, expression of the full length 16-fold mutated BoNT/E did not provide soluble protein, possibly due to an interference of the interaction between LC and the translocation domain. Reversion of individual mutations revealed the E159L and S162Q substitutions, critical for redirecting LC/E activity toward PTEN, as main culprits for the solubility issue. To overcome this problem, we applied a methodology proved successful years ago, harnessing a proteolytically inactive variant of BoNT type D (BoNT/Di) as neurospecific delivery system for cargo proteins. The fusion protein LCE-16x-BoNT/Di could be produced in sufficient yields. Activity tests using rat cerebellar granule neurons showed BoNT/E-like activity for LC/E-wt-BoNT/Di, but no PTEN-directed activity for LC/E-16x-BoNT/Di.

The usefulness of botulinum toxin injections in oncology - Clinical and laboratory perspectives

The use of botulinum toxins in various oncological conditions brings long-term results in the treatment of chronic pain without burdening internal organs, as is the case with the use of opioids. Numerous reports indicate a possible apoptotic effect achieved in vitro and in vivo. Most literature data suggest that using botulinum toxins to support oncological treatment gives positive results, and in most cases, it is free of side effects. The article reviews the literature on the use of botulinum toxins in experiments carried out on cancer cell lines and their impact on cancer at the level of reactions occurring at the cellular level. This literature review presents a collection of the most important reports on using various types of botulinum toxins in supporting oncological therapies, considering their analgesic and apoptotic effects. The work presents comprehensive research on large groups of patients, the most important case reports, and clinical trials. The collected information seems to confirm that using botulinum toxins creates an opportunity to support oncological therapies with comprehensive benefits for the patient, improving the quality of life and anticancer effect.

New Engineered-Chimeric Botulinum Neurotoxin Mutant Acts as an Effective Bivalent Vaccine Against Botulinum Neurotoxin Serotype A and E

Botulinum neurotoxins (BoNTs), including serotypes A and E, are potent biotoxins known to cause human poisoning. In addition to the critical protective antigen found in the full BoNT molecule, the receptor binding domain (Hc domain), BoNTs also harbour another essential protective antigen-the light chain-translocation domain (L-HN domain). Leveraging these pivotal protective antigens, we genetically engineered a series of inactivated chimeric molecules incorporating L-HN and Hc domains of BoNT/A and E. The structure of these chimeric molecules, mirror BoNT/A and E, but are devoid of enzyme activity. Experimental findings demonstrated that a lead candidate mEL-HN-mAHc harnessing the inactivated protease LCHN/E with the mutated gangliosides binding site Hc/A (mE-mA) elicited robust immune protection against BoNT/A and E simultaneously in a mouse model, requiring low immune dosages and minimal immunisations. Moreover, mE-mA exhibited high protective efficacy against BoNT/A and E in guinea pigs and New Zealand white rabbits, resulting in elevated neutralising antibody titres. Furthermore, mE-mA proved to be a more stable and safer vaccine compared to formaldehyde-inactivated toxoid. Our data underscore the genetically engineered mE-mA as a highly effective bivalent vaccine against BoNT/A and E, paving the way for the development of polyvalent vaccines against biotoxins.

Botulism: An Overlooked Cause of Bulbar Weakness in Intensive Care - A Case Report

Introduction

Botulism is a rare but potentially life-threatening syndrome caused by botulinum neurotoxin. The classic presentation of botulism is the acute onset of bilateral cranial neuropathies associated with symmetric descending weakness. The antitoxin is the main therapeutic option for botulism, in addition to supportive care with intubation and mechanical ventilation when necessary. The outcome is usually favorable, with a slow but full neurological recovery. This case presents a difficult diagnosis of the sporadic form of adult intestinal toxemia, with a delayed diagnosis.

Case Presentation

We report a 64-year-old patient who presented in a confused state with weakness in the limbs, bilateral ptosis, and dysarthria. Because of disease progression with respiratory compromise, the patient was transferred to the intensive care unit (ICU) and intubated. The diagnosis of botulism was eventually confirmed in the stool 46 days after presentation. By the end of follow-up, the patient still received rehabilitation. The outcome was good, except for the concomitant neurodegenerative disorder with the need for institutionalization at a residential care center.

Conclusion

This case report illustrates the difficulties in diagnosing a patient with botulism in the ICU, especially if associated with comorbidities. Delayed diagnosis and misdiagnosis are common because of the rarity of the disease and overlapping signs and symptoms with other neurological diseases. Increasing the awareness of this disease is important to prevent mortality and morbidity.

An Advanced Sensing Approach to Biological Toxins with Localized Surface Plasmon Resonance Spectroscopy Based on Their Unique Protein Quaternary Structures

Botulinum neurotoxins (BoNTs), ricin, and many other biological toxins are called AB toxins possessing heterogeneous A and B subunits. We propose herein a quick and safe sensing approach to AB toxins based on their unique quaternary structures. The proposed approach utilizes IgG antibodies against their A-subunits in combination with those human cell-membrane glycolipids that act as the natural ligands of B-subunits. In practice, an IgG antibody against the A-subunit of a target toxin is selected from commercially available sources and immobilized on the surface of Au nanoparticles to constitute a multivalent IgG/Au nanoconjugate. The derived IgG/Au conjugate is used in the pretreatment process of test samples for deactivating biological toxins in the form of a ternary toxin/antibody/Au complex. This process is implemented in advance to reduce the risk of handling biological toxins in laboratory work. On the other hand, the human glycolipid is immobilized on a tiny glass plate and used as a biosensor chip. The biosensor chip is set in the chamber of a flow sensing system using localized surface plasmon resonance (LSPR) spectrometry available in portable size at relatively low cost. In principle, the LSPR sensing system enables us to perform a rapid and selective detection for different kinds of biological toxins if the human glycolipid is correctly selected and installed in the sensing system. In the present LSPR sensing approach, a target AB toxin may have been deactivated during the pretreatment process. The test sample containing the deactivated AB toxin becomes a real target to be analyzed by the sensing system. In the present, we describe the concept of employing the commercially available IgG antibody in the pretreatment process followed by a typical procedure for converting it into the multivalent antibody/Au nanoconjugate and its preliminary applications in the LSPR detection of a ricin homologue (RCA120) and BoNTs in different serotypes. The tested LSPR sensing approach has worked very well for the ricin homologue and certain serotypes of botulinum neurotoxins like BoNT/A, indicating that the prior deactivation process at their A-domains causes no significant damage to the function of their B-domains with respect to determining the host cell-membrane glycolipid. The experimental results also indicated that LSPR responses from these pretreated AB toxins are significantly amplified. That is obviously thanks to the presence of Au nanoparticles in the multivalent IgG/Au nanoconjugate. We suggest in conclusion that the proposed LSPR sensing approach will provide us with a safe and useful tool for the study of biological AB toxins based on their unique quaternary protein structures.

Neutralizing chimeric heavy-chain antibody targeting the L-HN domain of Clostridium botulinum neurotoxin type F

Botulinum toxin (BoNT) from Clostridium botulinum is the most toxic biotoxin known and is also an important bioterrorism agent. After poisoning, the only effective treatment is injection of antitoxin. However, neutralizing nanoantibodies are safer and more effective, representing a promising therapeutic approach. Therefore, it is important to obtain effective neutralizing nanoantibodies. Hence, the present study aimed to construct a phage antibody library by immunizing a camel and screening specific clones that bind to the L-HN domain of BoNT/F and constructing chimeric heavy-chain antibodies by fusing them with a human Fc fragment. The antibodies' affinity and in vivo neutralizing activities were evaluated. The results showed that 2 µg of F20 antibody could completely neutralize 20 × the median lethal dose (LD50) of BoNT/F in vitro. Injection of 5 mg/kg F20 at 1 h, 2 h, 3 h, and 4 h into mice after BoNT/F challenge resulted in complete survival in vivo. Overall, the antibody might be a candidate for the development of new drugs to treat botulism.

Development and characterization of a novel neutralizing scFv vectored immunoprophylaxis against botulinum toxin type A

Botulinum toxin is a protein toxin secreted by Clostridium botulinum that is strongly neurotoxic. Due to its characteristics of being super toxic, quick acting, and difficult to prevent, the currently reported antiviral studies focusing on monoclonal antibodies have limited effectiveness. Therefore, for the sake of effectively prevention and treatment of botulism and to maintain country biosecurity as well as the health of the population, in this study, we intend to establish a single chain antibody (scFv) targeting the carboxyl terminal binding functional domain of the botulinum neurotoxin heavy chain (BONT/AHc) of botulinum neurotoxin type A, and explore the value of a new passive immune method in antiviral research which based on adeno-associated virus (AAV) mediated vector immunoprophylaxis (VIP) strategy. The scFv small-molecular single-chain antibody sequenced, designed, constructed, expressed and purified by hybridoma has high neutralising activity and affinity level, which can lay a good foundation for the modification and development of antibody engineering drugs. In vivo experiments, AAV-mediated scFv engineering drug has good anti-BONT/A toxin neutralisation ability, has advantages of simple operation, stable expression and good efficacy, and may be one of the effective treatment strategies for long-term prevention and protection of BONT/A botulinum neurotoxin.

Botulinum Toxin-A Infiltration to Control Post-Operative Pain after Mastectomy and Expander Reconstruction as Potentially Useful Tool: A Narrative Review

Botulinum toxin-A (BTX-A), a neurotoxin produced by Clostridium botulinum, was assessed for relieving implant-related pectoralis major muscle's painful spasms. In detail, 100 units of BTX-A can reduce muscle activity and, as a consequence, muscle spasms. The latter is considered the leading cause of post-operative pain after the sub-pectoral tissue expansion, sometimes leading to early expanders' removal. In addition, women choosing post-mastectomy reconstruction surgery seem to suffer worse post-operative pain than those who stop at the mastectomy stage. However, there is no unanimous consensus concerning the potential benefits of BTX-A in reducing pain related to the sub-pectoral placement of tissue expanders in breast reconstruction due to the exiguity of evidence. Therefore, this review aims to describe BTX-A-related evidence in this reconstruction setting. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Are We Missing Something About the Maximum Dosing of Botulinum Toxin Type A1 in Adult and Pediatric Patients with Spasticity?

Botulinum toxin type A1 is a first-line treatment for adult and pediatric spasticity. However, when considering the quantity of 150 kDa neurotoxin protein in relation to patient weight and the maximum recommended dose for treating adult and pediatric patients with spasticity, several concerns arise. First, the therapeutic margin (the ratio of the actual maximum quantity of toxin recommended for treating adult spasticity to its median lethal dose) appears to be relevant. Second, there is no consistency between adult and pediatric dosing of botulinum toxin type A1 for spasticity. The third point concerns the suitability of the recommended doses for treating spasticity in pediatric patients. Based on the average body weight of American children and adolescents, the maximum weight-based doses for abobotulinumtoxinA and onabotulinumtoxinA could be administered to children as young as 9 years old. Additionally, the maximum weight-based dose for incobotulinumtoxinA could be administered to children as young as 6 years old. The final point concerns managing the maximum dose of BoNT/A1 in pediatric patients with spasticity who weigh more than 25 kg for incobotulinumtoxinA, or more than 34 kg for abobotulinumtoxinA and onabotulinumtoxinA. No labeled recommendations are given on the weight cut-off for transitioning to adult dosing in pediatric patients.

Continuous Treatment with IncobotulinumtoxinA Despite Presence of BoNT/A Neutralizing Antibodies: Immunological Hypothesis and a Case Report

Botulinum Neurotoxin A (BoNT/A) is a bacterial protein that has proven to be a valuable pharmaceutical in therapeutic indications and aesthetic medicine. One major concern is the formation of neutralizing antibodies (nAbs) to the core BoNT/A protein. These can interfere with the therapy, resulting in partial or complete antibody (Ab)-mediated secondary non-response (SNR) or immunoresistance. If titers of nAbs reach a level high enough that all injected BoNT/A molecules are neutralized, immunoresistance occurs. Studies have shown that continuation of treatment of neurology patients who had developed Ab-mediated partial SNR against complexing protein-containing (CPC-) BoNT/A was in some cases successful if patients were switched to complexing protein-free (CPF-) incobotulinumtoxinA (INCO). This seems to contradict the layperson's basic immunological understanding that repeated injection with the same antigen BoNT/A should lead to an increase in antigen-specific antibody titers. As such, we strive to explain how immunological memory works in general, and based on this, we propose a working hypothesis for this paradoxical phenomenon observed in some, but not all, neurology patients with immunoresistance. A critical factor is the presence of potentially immune-stimulatory components in CPC-BoNT/A products that can act as immunologic adjuvants and activate not only naïve, but also memory B lymphocyte responses. Furthermore, we propose that continuous injection of a BoN/TA formulation with low immunogenicity, e.g., INCO, may be a viable option for aesthetic patients with existing nAbs. These concepts are supported by a real-world case example of a patient with immunoresistance whose nAb levels declined with corresponding resumption of clinical response despite regular INCO injections.

Neutralization mechanism of human monoclonal antibodies against type B botulinum neurotoxin

Botulism is a deadly neuroparalytic condition caused by the botulinum neurotoxin (BoNT) produced by Clostridium botulinum and related species. Toxin-neutralizing antibodies are the most effective treatments for BoNT intoxication. We generated human monoclonal antibodies neutralizing type B botulinum neurotoxin (BoNT/B), designated M2 and M4. The combination of these antibodies exhibited a strong neutralizing effect against BoNT/B toxicity. In this study, we analyzed the mechanisms of action of these antibodies in vitro. M4 binds to the C-terminus of the heavy chain (the receptor-binding domain) and inhibits BoNT/B binding to neuronal PC12 cells. Although M2 recognized the light (L) chain (the metalloprotease domain), it did not inhibit substrate (VAMP2) cleavage in the cleavage assay. M2 increased the surface localization of BoNT/B in PC12 cells at a later time point, suggesting that M2 inhibits the translocation of the L chain from synaptic vesicles to the cytosol. These results indicate that M2 and M4 inhibit the different processes of BoNT/B individually and that multistep inhibition is important for the synergistic effect of the combination of monoclonal antibodies. Our findings may facilitate the development of effective therapeutic antibodies against BoNTs.

Repeated unilateral injections of botulinum toxin in masticatory muscles in adult rats do not amplify condylar and alveolar bone loss nor modify the volume of the hypertrophic bone proliferation at enthesis

OBJECTIVES

Botulinum toxin is used in human in repeatedly masticatory muscles injections. A single BTX injection in animal induces mandibular bone loss with a muscle enthesis hypertrophic metaplasia. Our aim was to evaluate mandibular bone changes after unilateral repeated injections of BTX in adult rats.

STUDY DESIGN

Mature male rats were randomized into 3 groups: one, two or three injections. Each rat received injections in right masseter and temporalis muscles. The left side was the control side. Microcomputed tomography was used to perform 2D and 3D analyses.

RESULTS

Bone loss was evidenced on the right sides of alveolar and condylar bone. Alveolar bone volume increased in both control left side and injected right side whereas condylar bone volume remained constant in all groups, for both sides. Enthesis bone hypertrophic metaplasias were evidenced on the BTX injected sides without any modification with the number of injections.

CONCLUSION

BTX repeated injections in masticatory muscles lead to major mandibular condylar and alveolar bone loss that does not worsen. They lead to the occurrence of an enthesis bone proliferation that is not dependent on the number of injections. These results are an argument for the safety of BTX injections in masticatory muscles in human.

Insights from 25 years of onabotulinumtoxinA in migraine - mechanisms and management

OnabotulinumtoxinA (BTX-A) was first linked to beneficial effects in migraine 25 years ago and was approved by the FDA for preventive treatment of chronic migraine in 2010. The treatment has since had a major impact on the well-being of people with chronic migraine. The clinical development programme for BTX-A and research since its approval have provided insights into the neuromodulatory sensory effect of BTX-A, how it can control chronic migraine despite its peripheral action, and the underlying biology of migraine as a disease. In this Review, we consider the impact that BTX-A has had on the management of chronic migraine and on the research field. We discuss the insights provided by clinical research, encompassing the clinical trials and subsequent real-world evidence, and the mechanistic insights provided by preclinical and translational research. We also provide an overview of future directions of research in the field BTX-A in migraine and the clinical translation of this research.

Botulinum toxin type A is a potential therapeutic drug for chronic orofacial pain

BACKGROUND

Botulinum toxin type A (BTX-A), produced by the gram-positive anaerobic bacterium Clostridium botulinum, acts by cleaving synaptosome-associated protein-25 (SNAP-25), an essential component of the presynaptic neuronal membrane that is necessary for fusion with the membrane proteins of neurotransmitter-containing vesicles. Recent studies have highlighted the efficacy of BTX-A in treating chronic pain conditions, including lower back pain, chronic neck pain, neuropathic pain, and trigeminal neuralgia, particularly when patients are unresponsive to traditional painkillers. This review focuses on the analgesic effects of BTX-A in various chronic pain conditions, with a particular emphasis on the orofacial region.

HIGHLIGHT

This review focuses on the mechanisms by which BTX-A induces analgesia in patients with inflammatory and temporomandibular joint pain. This review also highlights the fact that BTX-A can effectively manage neuropathic pain and trigeminal neuralgia, which are difficult-to-treat chronic pain conditions. Herein, we present a comprehensive assessment of the central analgesic effects of BTX-A and a discussion of its various applications in clinical dental practice.

CONCLUSION

BTX-A is an approved treatment option for various chronic pain conditions. Although there is evidence of axonal transport of BTX-A from peripheral to central endings in motor neurons, the precise mechanism underlying its pain-modulating effects remains unclear. This review discusses the evidence supporting the effectiveness of BTX-A in controlling chronic pain conditions in the orofacial region. BTX-A is a promising therapeutic agent for treating pain conditions that do not respond to conventional analgesics.

Potency Evaluations of Recombinant Botulinum Neurotoxin A1 Mutants Designed to Reduce Toxicity

Recombinant mutant holotoxin BoNTs (rBoNTs) are being evaluated as possible vaccines against botulism. Previously, several rBoNTs containing 2-3 amino acid mutations in the light chain (LC) showed significant decreases in toxicity (2.5-million-fold-12.5-million-fold) versus wild-type BoNT/A1, leading to their current exclusion from the Federal Select Agent list. In this study, we added four additional mutations in the receptor-binding domain, translocation domain, and enzymatic cleft to further decrease toxicity, creating 7M rBoNT/A1. Due to poor expression in E. coli, 7M rBoNT/A1 was produced in an endogenous C. botulinum expression system. This protein had higher residual toxicity (LD50: 280 ng/mouse) than previously reported for the catalytically inactive rBoNT/A1 containing only three of the mutations (>10 µg/mouse). To investigate this discrepancy, several additional rBoNT/A1 constructs containing individual sets of amino acid substitutions from 7M rBoNT/A1 and related mutations were also endogenously produced. Similarly to endogenously produced 7M rBoNT/A1, all of the endogenously produced mutants had ~100-1000-fold greater toxicity than what was reported for their original heterologous host counterparts. A combination of mutations in multiple functional domains resulted in a greater but not multiplicative reduction in toxicity. This report demonstrates the impact of production systems on residual toxicity of genetically inactivated rBoNTs.

Activity of botulinum neurotoxin X and its structure when shielded by a non-toxic non-hemagglutinin protein

Botulinum neurotoxins (BoNTs) are the most potent toxins known and are used to treat an increasing number of medical disorders. All BoNTs are naturally co-expressed with a protective partner protein (NTNH) with which they form a 300 kDa complex, to resist acidic and proteolytic attack from the digestive tract. We have previously identified a new botulinum neurotoxin serotype, BoNT/X, that has unique and therapeutically attractive properties. We present the cryo-EM structure of the BoNT/X-NTNH/X complex and the crystal structure of the isolated NTNH protein. Unexpectedly, the BoNT/X complex is stable and protease-resistant at both neutral and acidic pH and disassembles only in alkaline conditions. Using the stabilizing effect of NTNH, we isolated BoNT/X and showed that it has very low potency both in vitro and in vivo. Given the high catalytic activity and translocation efficacy of BoNT/X, low activity of the full toxin is likely due to the receptor-binding domain, which presents very weak ganglioside binding and exposed hydrophobic surfaces.

The Potential Therapeutic Effects of Botulinum Neurotoxins on Neoplastic Cells: A Comprehensive Review of In Vitro and In Vivo Studies

A systematic review of the literature found fifteen articles on the effect of a botulinum toxin on neoplastic cell lines and eight articles on in vivo neoplasms. The reported in vitro effects rely on high doses or the mechanical disruption of cell membranes to introduce the botulinum neurotoxin into the cell cytoplasm. The potency of the botulinum neurotoxin to intoxicate non-neuronal cells (even cell lines expressing an appropriate protein receptor) is several orders of magnitude lower compared to that to intoxicate the primary neurons. The data suggest that the botulinum toxin disrupts the progression of cancer cells, with some studies reporting apoptotic effects. A majority of the data in the in vivo studies also showed similar results. No safety issues were disclosed in the in vivo studies. Limited studies have suggested similar anti-neoplastic potential for the clostridium difficile. New modes of delivery have been tested to enhance the in vivo delivery of the botulinum toxin to neoplastic cells. Careful controlled studies are necessary to demonstrate the efficacy and safety of this mode of anti-neoplastic treatment in humans.

Effectiveness of 0.3% Hyaluronic Acid Eye Drops for Benign Essential Blepharospasm and Hemifacial Spasm with Botulinum Toxin-induced Dry Eye

Background

This study evaluates the effectiveness of 0.3% hyaluronic acid (HA) eye drops in patients receiving concurrent botulinum toxin (BoNT) injections for benign essential blepharospasm (BEB) or hemifacial spasm (HFS).

Methods

This randomized controlled cross-over trial study involved 14 patients with BEB and 33 patients with HFS randomized into two groups (early treatment and deferred treatment) for 3 months of treatment with 0.3% HA eye drops. Data collected at baseline, 3 months, and 6 months included Blepharospasm Severity Scale (BSS) score in patients with BEB; Samsung Medical Class Grading Scale score in patients with HFS; and dry eye symptoms, lower eyelid tear meniscus height (TMH), tear breakup time (TBUT), and corneal fluorescein staining in both groups.

Results

After 3 months of 0.3% HA instillation, patients with BEB in both groups showed significant improvement in BSS, TMH, TBUT, and the amelioration of subjective dry eye symptoms and corneal staining (P < 0.05). However, discontinuation of 0.3% HA eye drops worsened BSS, TMH, and TBUT. Patients with HFS also experienced significant improvement in Samsung Medical Class score, subjective dry eye symptoms, and objective corneal findings (P < 0.05).

Conclusions

Treatment with 0.3% HA eye drops led to significant improvement in spasm severity, and dry eye parameters, after 3 months of instillation in patients with BEB or HFS during concurrent treatment with BoNT injections. The 0.3% HA eye drops were safe and might serve as an add-on treatment for symptom improvement.

Gait Reconstruction Strategy Using Botulinum Toxin Therapy Combined with Rehabilitation

Numerous studies have established a robust body of evidence for botulinum toxin A (BoNT-A) therapy as a treatment for upper motor neuron syndrome. These studies demonstrated improvements in spasticity, range of joint motion, and pain reduction. However, there are few studies that have focused on improvement of paralysis or functional enhancement as the primary outcome. This paper discusses the multifaceted aspects of spasticity assessment, administration, and rehabilitation with the goal of optimising the effects of BoNT-A on lower-limb spasticity and achieving functional improvement and gait reconstruction. This paper extracts studies on BoNT-A and rehabilitation for the lower limbs and provides new knowledge obtained from them. From these discussion,, key points in a walking reconstruction strategy through the combined use of BoNT-A and rehabilitation include: (1) injection techniques based on the identification of appropriate muscles through proper evaluation; (2) combined with rehabilitation; (3) effective spasticity control; (4) improvement in ankle joint range of motion; (5) promotion of a forward gait pattern; (6) adjustment of orthotics; and (7) maintenance of the effects through frequent BoNT-A administration. Based on these key points, the degree of muscle fibrosis and preintervention walking speed may serve as indicators for treatment strategies. With the accumulation of recent studies, a study focusing on walking functions is needed. As a result, it is suggested that BoNT-A treatment for lower limb spasticity should be established not just as a treatment for spasticity but also as a therapeutic strategy in the field of neurorehabilitation aimed at improving walking function.

Botulinum Toxin-A for the Treatment of Myogenous Temporomandibular Disorders: An Umbrella Review of Systematic Reviews

OBJECTIVE

Temporomandibular disorders (TMDs) encompass several conditions that cause pain and impair function of the masticatory muscles (M-TMDs) and temporomandibular joints. There is a large interest among clinicians and researchers in the use of botulinum toxin-A (BoNT-A) as a treatment for M-TMD. However, due to the lack of consistent evidence regarding the efficacy as well as adverse events of BoNT-A, clinical decision making is challenging. Therefore, this umbrella review aimed to systematically assess systematic reviews (SRs) evaluating BoNT-A treatment effects on pain intensity, mandibular movements, and adverse events in patients with M-TMDs.

METHOD

An electronic search was undertaken in the databases MEDLINE, EMBASE, CINAHL, Cochrane Central Registry of Controlled Trials (CENTRAL), Web of Science, Epistemonikos, ClinicalTrials.gov, and ICTRP to identify SRs investigating BoNT-A effects on M-TMDs, published from the inception of each database until 6 December 2023. The quality of evidence was rated according to the critical appraisal checklist developed by the umbrella review methodology working group. Only high-quality SRs were included.

RESULTS

In total, 18 SRs were included. BoNT-A was shown to be more effective than placebo to reduce pain intensity, but not compared to standard treatments. Additionally, BoNT-A was not superior to placebo or standard treatments regarding improvement of mandibular movements. BoNT-A was considered to have a higher risk for adverse events on muscle and bony tissue compared with other treatments.

CONCLUSION

The synthesis in this umbrella review provides the highest level of evidence present. Taken together, there are indications of effectiveness of BoNT-A for treatment of M-TMDs, supported by moderate evidence. However, considering the risk of causing serious adverse events, treatment with BoNT-A is recommended to be the last treatment alternative.

Improving Spasticity by Using Botulin Toxin: An Overview Focusing on Combined Approaches

Spasticity is a very common sign in the neurological field. It can be defined as "a motor disorder marked by a velocity-dependent increase in muscle tone or tonic stretch reflexes" associated with hypertonia. It leads to a high risk of limb deformities and pain that prejudices residual motor function, impairing quality of life". The treatment of spasticity depends on its severity and its location and, in general, it is based on rehabilitation, oral therapies (the gamma-aminobutyric acid b agonist baclofen) and injectable medications (i.e., botulin toxins, acting on polysynaptic reflex mechanisms). The botulin toxin type A (BoNT-A) injection has been effectively used to improve different types of spasticity. However, when BoNT-A is not sufficient, a combination of nonpharmacological approaches could be attempted. Therefore, additional intervention, such as conventional physical therapy by itself or further combined with robotic gait training, may be needed. Indeed, it has been shown that combination of BoNT-A and robotics has a positive effect on activity level and upper limb function in patients with stroke, including those in the chronic phase. The aim of this review is to evaluate the efficacy of pharmacological or nonpharmacological treatment in combination with BoNT-A injections on spasticity. The combined therapy of BoNT with conventional or adjunct activities or robot-assisted training, especially with end-effectors, is a valid tool to improve patients' performance and outcomes. The combined strategies might rise the toxin's effect, lowering its dosages of botulinum and reducing side effects and costs.

Update on Non-Interchangeability of Botulinum Neurotoxin Products

The growing use of botulinum neurotoxins (BoNTs) for medical and aesthetic purposes has led to the development and marketing of an increasing number of BoNT products. Given that BoNTs are biological medications, their characteristics are heavily influenced by their manufacturing methods, leading to unique products with distinct clinical characteristics. The manufacturing and formulation processes for each BoNT are proprietary, including the potency determination of reference standards and other features of the assays used to measure unit potency. As a result of these differences, units of BoNT products are not interchangeable or convertible using dose ratios. The intrinsic, product-level differences among BoNTs are compounded by differences in the injected tissues, which are innervated by different nerve fiber types (e.g., motor, sensory, and/or autonomic nerves) and require unique dosing and injection sites that are particularly evident when treating complex therapeutic and aesthetic conditions. It is also difficult to compare across studies due to inherent differences in patient populations and trial methods, necessitating attention to study details underlying each outcome reported. Ultimately, each BoNT possesses a unique clinical profile for which unit doses and injection paradigms must be determined individually for each indication. This practice will help minimize unexpected adverse events and maximize efficacy, duration, and patient satisfaction. With this approach, BoNT is poised to continue as a unique tool for achieving individual goals for an increasing number of medical and aesthetic indications.

Dual-Modal Cellular Nanoparticles for Continuous Neurotoxin Detoxification

Neurotoxins are known for their extreme lethality. However, due to their enormous diversity, effective and broad-spectrum countermeasures are lacking. This study presents a dual-modal cellular nanoparticle (CNP) formulation engineered for continuous neurotoxin neutralization. The formulation involves encapsulating the metabolic enzyme N-sulfotransferase (SxtN) into metal-organic framework (MOF) nanoparticle cores and coating them with a natural neuronal membrane, termed "Neuron-MOF/SxtN-NPs". The resulting nanoparticles combine membrane-enabled broad-spectrum neurotoxin neutralization with enzyme payload-enabled continuous neurotoxin neutralization. The studies confirm the protection of the enzyme payload by the MOF core and validate the continuous neutralization of saxitoxin (STX). In vivo studies conducted using a mouse model of STX intoxication reveal markedly improved survival rates compared with control groups. Furthermore, acute toxicity assessments show no adverse effects associated with the administration of Neuron-MOF/SxtN-NPs in healthy mice. Overall, Neuron-MOF/SxtN-NPs represent a unique biomimetic nanomedicine platform poised to effectively neutralize neurotoxins, marking an important advancement in the field of countermeasure nanomedicine.

Embracing the Versatility of Botulinum Neurotoxins in Conventional and New Therapeutic Applications

Botulinum neurotoxins (BoNTs) have been used for almost half a century in the treatment of excessive muscle contractility. BoNTs are routinely used to treat movement disorders such as cervical dystonia, spastic conditions, blepharospasm, and hyperhidrosis, as well as for cosmetic purposes. In addition to the conventional indications, the use of BoNTs to reduce pain has gained increased recognition, giving rise to an increasing number of indications in disorders associated with chronic pain. Furthermore, BoNT-derived formulations are benefiting a much wider range of patients suffering from overactive bladder, erectile dysfunction, arthropathy, neuropathic pain, and cancer. BoNTs are categorised into seven toxinotypes, two of which are in clinical use, and each toxinotype is divided into multiple subtypes. With the development of bioinformatic tools, new BoNT-like toxins have been identified in non-Clostridial organisms. In addition to the expanding indications of existing formulations, the rich variety of toxinotypes or subtypes in the wild-type BoNTs associated with new BoNT-like toxins expand the BoNT superfamily, forming the basis on which to develop new BoNT-based therapeutics as well as research tools. An overview of the diversity of the BoNT family along with their conventional therapeutic uses is presented in this review followed by the engineering and formulation opportunities opening avenues in therapy.

Underreporting or Failed Notification? Global Botulism Reporting, 2000-2022

Botulism is a rare, potentially fatal illness caused by botulinum toxins produced by Clostridium bacteria. There are no coordinated worldwide reporting mechanisms for botulism cases and therefore few reliable case frequency estimates. This study aimed to establish an international benchmark for case frequency to determine estimated global rates of underreporting of botulism cases. To this end, a comprehensive, multilingual search of major global and national databases, including gray data and government sources, was performed. Data from case series were pooled, standardized against United Nations midyear population estimates, and analyzed using Kolmogorov-Smirnov tests to identify normally distributed data series. National incidence rates of normally distributed series were compared with that of the United States, which was considered the gold standard due to its extensive data reported for 2004-2018. A total of 6,932 botulism cases from 59 nations were identified in the literature, with a global case fatality rate of 1.37%. The national mean incidence rate ranged from 0.00 to 8.04 cases per million people, with an international mean incidence rate of 0.62 cases per million people. At the continent level, incidence rates tended toward normal distributions, although few countries outside of North America and Europe exhibited normal distributions. Based on comparisons with the US standard, an estimated 88.71% of botulism cases worldwide were unreported in 2016. Better awareness of botulism among healthcare professionals, coordinated global reporting mechanisms, and research on additional contributing factors to underreporting would enable better understanding of global case frequency, thereby potentially reducing the global incidence of botulism and improving outcomes.

Intramuscular Botulinum Neurotoxin Serotypes E and A Elicit Distinct Effects on SNAP25 Protein Fragments, Muscular Histology, Spread and Neuronal Transport: An Integrated Histology-Based Study in the Rat

Botulinum neurotoxins E (BoNT/E) and A (BoNT/A) act by cleaving Synaptosome-Associated Protein 25 (SNAP25) at two different C-terminal sites, but they display very distinct durations of action, BoNT/E being short acting and BoNT/A long acting. We investigated the duration of action, spread and neuronal transport of BoNT/E (6.5 ng/kg) and BoNT/A (125 pg/kg) after single intramuscular administrations of high equivalent efficacious doses, in rats, over a 30- or 75-day periods, respectively. To achieve this, we used (i) digit abduction score assay, (ii) immunohistochemistry for SNAP25 (N-ter part; SNAP25N-ter and C-ter part; SNAP25C-ter) and its cleavage sites (cleaved SNAP25; c-SNAP25E and c-SNAP25A) and (iii) muscular changes in histopathology evaluation. Combined in vivo observation and immunohistochemistry analysis revealed that, compared to BoNT/A, BoNT/E induces minimal muscular changes, possesses a lower duration of action, a reduced ability to spread and a decreased capacity to be transported to the lumbar spinal cord. Interestingly, SNAP25C-ter completely disappeared for both toxins during the peak of efficacy, suggesting that the persistence of toxin effects is driven by the persistence of proteases in tissues. These data unveil some new molecular mechanisms of action of the short-acting BoNT/E and long-acting BoNT/A, and reinforce their overall safety profiles.

Association analyses between the variants of SNAP25, SV2C and ST3GAL2 and the efficacy of botulinum toxin A in the treatment of the primary Meige syndrome

Objective

Individual differences were observed in the clinical efficacy of Botulinum toxin A (BoNT-A) in the treatment of the primary Meige syndrome. Our study aimed to explore the potential associations between the clinical efficacy of BoNT-A in the treatment of the primary Meige syndrome and variants of SNAP25, SV2C and ST3GAL2, which are involving in the translocation of the BoNT-A in vivo.

Methods

Patients with the primary Meige syndrome treated with BoNT-A were enrolled. Clinical efficacy was evaluated by the maximum improvement rate of motor symptoms and the duration of efficacy. Variants of SNAP25, SV2C and ST3GAL2 were obtained by Sanger sequencing. Another cohort diagnosed with primary cervical dystonia was also enrolled in the replication stage.

Results

Among the 104 primary Meige syndrome patients, 80 patients (76.9%) had a good efficacy (the maximum improvement rate of motor symptoms ≥30%) and 24 (23. 1%) had a poor (the maximum improvement rate of motor symptoms <30%). As to the duration of efficacy, 52 patients (50.0%) had a long duration of efficacy (≥4 months), and 52 (50.0%) had a short (<4 months). In terms of primary Meige syndrome, SNAP25 rs6104571 was found associating with the maximum improvement rate of motor symptoms (Genotype: P = 0.02, OR = 0.26; Allele: P = 0.013, OR = 0.29), and SV2C rs31244 was found associating with the duration of efficacy (Genotype: P = 0.024, OR = 0.13; Allele: P = 0.012, OR = 0.13). Besides, we also conducted the association analyses between the variants and BoNT-A-related adverse reactions. Although, there was no statistical difference between the allele of SV2C rs31244 and BoNT-A-related adverse reactions, there was a trend (P = 0.077, OR = 2.56). In the replication stage, we included 39 patients with primary cervical dystonia to further expanding the samples' size. Among the 39 primary cervical dystonia patients, 25 patients (64.1%) had a good efficacy (the maximum improvement rate of motor symptoms ≥50%) and 14 (35.9%) had a poor (the maximum improvement rate of motor symptoms <50%). As to the duration of efficacy, 32 patients (82.1%) had a long duration of efficacy (≥6 months), and 7 (17.9%) had a short (<6 months). Integrating primary Meige syndrome and primary cervical dystonia, SV2C rs31244 was still found associating with the duration of efficacy (Genotype: P = 0.002, OR = 0. 23; Allele: P = 0.001, OR = 0. 25).

Conclusion

In our study, SNAP25 rs6104571 was associated with the maximum improvement rate of motor symptoms in patients with primary Meige syndrome treated with BoNT-A, and patients carrying this variant had a lower improvement rate of motor symptoms. SV2C rs31244 was associated with duration of treatment in patients with primary Meige syndrome treated with BoNT-A and patients carrying this variant had a shorter duration of treatment. Patients with primary Meige syndrome carrying SV2C rs31244 G allele have an increase likelihood of BoNT-A-related adverse reactions. Involving 39 patients with primary cervical dystonia, the results further verify that SV2C rs31244 was associated with duration of treatment and patients carrying this variant had a shorter duration of treatment.

Beyond Pain: The Effects of OnabotulinumtoxinA Therapy on Sensitization and Interictal Symptoms in Chronic Migraine

Chronic migraine is a disease with a high burden on patients from both a working and quality of life point of view. The pathophysiology of this subtype of migraine is due to several factors, such as medication overuse. Nevertheless, the detrimental recurring of headache attacks with central and peripheral sensitization plays a central role and explains some additional symptoms complained about by these patients even in the interictal phase. OnabotulinumtoxinA is a therapy indicated for chronic migraine since it has proven to reduce peripheral sensitization, showing even efficacy on central symptoms. The aim of this narrative review is to present the current evidence regarding the effect of OnabotulinumtoxinA on sensitization and interictal symptoms.

Structural basis for antiepileptic drugs and botulinum neurotoxin recognition of SV2A

More than one percent of people have epilepsy worldwide. Levetiracetam (LEV) is a successful new-generation antiepileptic drug (AED), and its derivative, brivaracetam (BRV), shows improved efficacy. Synaptic vesicle glycoprotein 2a (SV2A), a putative membrane transporter in the synaptic vesicles (SVs), has been identified as a target of LEV and BRV. SV2A also serves as a receptor for botulinum neurotoxin (BoNT), which is the most toxic protein and has paradoxically emerged as a potent reagent for therapeutic and cosmetic applications. Nevertheless, no structural analysis on AEDs and BoNT recognition by full-length SV2A has been available. Here we describe the cryo-electron microscopy structures of the full-length SV2A in complex with the BoNT receptor-binding domain, BoNT/A2 HC, and either LEV or BRV. The large fourth luminal domain of SV2A binds to BoNT/A2 HC through protein-protein and protein-glycan interactions. LEV and BRV occupy the putative substrate-binding site in an outward-open conformation. A propyl group in BRV creates additional contacts with SV2A, explaining its higher binding affinity than that of LEV, which was further supported by label-free spectral shift assay. Numerous LEV derivatives have been developed as AEDs and positron emission tomography (PET) tracers for neuroimaging. Our work provides a structural framework for AEDs and BoNT recognition of SV2A and a blueprint for the rational design of additional AEDs and PET tracers.

Genetics of migraine: complexity, implications, and potential clinical applications

Migraine is a common neurological disorder with large burden in terms of disability for individuals and costs for society. Accurate diagnosis and effective treatments remain priorities. Understanding the genetic factors that contribute to migraine risk and symptom manifestation could improve individual management. Migraine has a strong genetic basis that includes both monogenic and polygenic forms. Some distinct, rare, familial migraine subtypes are caused by pathogenic variants in genes involved in ion transport and neurotransmitter release, suggesting an underlying vulnerability of the excitatory-inhibitory balance in the brain, which might be exacerbated by disruption of homoeostasis and lead to migraine. For more prevalent migraine subtypes, genetic studies have identified many susceptibility loci, implicating genes involved in both neuronal and vascular pathways. Genetic factors can also reveal the nature of relationships between migraine and its associated biomarkers and comorbidities and could potentially be used to identify new therapeutic targets and predict treatment response.