Federal authorities are sounding the alarm about possibly counterfeit Botox that has left at least six people sick with botulism-like illnesses.

People in at least two states have been hospitalized after receiving botulinum toxin cosmetic injections, commonly known as Botox, that were administered in non-medical settings such as homes or cosmetic spas, officials said.

The CDC is now coordinating a multistate outbreak investigation, collaborating with the Food and Drug Administration and multiple health departments to determine what exactly is going on.

Health departments in Illinois and Tennessee have reported cases, with two people in each state hospitalized. According to NBC News, there are also four cases in Kentucky (two that required hospitalization) and suspected cases in Washington and Colorado.

In Illinois, the two individuals reported symptoms similar to botulism such as blurred/double vision, droopy face, fatigue, shortness of breath, difficulty breathing and hoarse voice following injection. The health department said both people had received injections from a licensed nurse in LaSalle County who was performing work outside her authority.

In Tennessee, four people reported similar symptoms after receiving cosmetic injections, and officials said their ongoing investigation suggests that the product administered was counterfeit.

“Receiving these treatments in unlicensed, unapproved settings can put you or your loved ones at serious risk for health problems,” Dr. Sameer Vohra, Illinois Department of Public Health director, said in a statement. “Please only seek cosmetic services under the care of licensed professionals trained to do these procedures and who use FDA approved products.”

Botulism is a rare, but potentially deadly illness characterized by muscle paralysis. It’s caused by a nerve toxin that is produced by a bacterium called Clostridium botulinum, which is found in nature. The purified form of the botulinum toxin is approved by the FDA for use by licensed healthcare providers as a cosmetic treatment.

Initial symptoms of botulism might include double or blurred vision, drooping eyelids, slurred speech, difficulty swallowing, dry mouth and difficulty breathing. These symptoms are typically followed by descending, symmetric muscle weakness that progresses over hours to days requiring hospitalization and specialized treatment with an anti-toxin.

Authorities are now warning health providers around the country, and especially emergency department staff, to be on the lookout for patients with symptoms that resemble botulism as an investigation into the source of the products continues.

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