At least 19 women in nine states reportedly became sick after they got Botox, either having gotten the injections from people who were never licensed or trained to give the shots or received them in “non-healthcare settings,” including homes or spas, the Centers for Disease Control and Prevention said Monday.

Nine of the 19 patients were hospitalized, the CDC said. Four “were treated with botulism antitoxin because of concerns that the botulinum toxin could have spread beyond the injection site.”

Botox uses a purified form of a neurotoxin called botulinum toxin that prevents muscles from moving for a period of time. The product is often used to prevent or ease facial wrinkles. When the toxin is found in food, it can lead to widespread paralysis and even death.

But when it is injected carefully, botulinum toxin is generally considered safe. Too much in the wrong places can be damaging, according to the CDC.

Cases have been detected in Colorado, Florida, Illinois, Kentucky, Nebraska, New Jersey, New York, Tennessee and Washington. No deaths have been reported.

It is unclear whether the reactions were the result of fake products, contamination or poor hygiene practices. The CDC’s investigation is ongoing, the agency said.

The Food and Drug Administration said in a statement Friday that it was involved with the investigation.

Warnings about medical procedures at unregulated med spas are rising. Colorado health officials told NBC News that they’re investigating a case of botulism-like illness after an unlicensed provider injected a patient with what was allegedly botulinum toxin. The Illinois patients received injections from a nurse “who was performing work outside her authority,” according to the state’s Public Health Department.

Problematic reactions to botulinum toxin injections include:

  • blurry or double vision
  • drooping eyelids
  • difficulty swallowing or breathing
  • dry mouth
  • slurred speech
  • fatigue and weakness.

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