Síndrome de Nicolau / Nicolau syndrome

Resumen El síndrome de Nicolau es una complicación infrecuente de la aplicación parenteral de diversos fármacos. Se caracteriza por la aparición de dolor, seguido de edema, eritema y luego una placa necrótica. Se reporta el caso de un hombre de 31 años que presenta este síndrome luego de la aplicación de penicilina benzatínica intramuscular. La biopsia apoyó el diagnóstico. Recibió tratamiento con enoxaparina y cilostazol con posterior mejoría.

Abstract Nicolau syndrome is a rare complication of the parenteral application of various drugs. It is char acterized by the appearance of pain, followed by edema, erythema, and then a necrotic plaque. We present the case of a 31-year-old male with this syndrome, after the application of intramuscular benzathine penicillin. The diagnosis was supported by the biopsy. He received treatment with enoxaparin and cilostazol with subsequent improvement.

Tratamiento y manejo fibrinolítico en síndrome de Nicolau: Caso clínico / Fibrinolytic treatment and management in Nicolau syndrome: Clinical case

RESUMEN Introducción: El síndrome de Nicolau (SN), conocido como embolia cutis medicamentosa o dermatitis livedoide es un acontecimiento adverso debido a la administración de inyecciones intramusculares, intraarteriales, subcutánea e incluso intraarticulares asociado a diversos fármacos1. Se desconoce toda la patogenia de este síndrome, pero se ha asociado a lesión vascular, trombosis arterial, espasmo reflejo de las arterias, oclusión vascular por microembolia e inflamación. Caso clínico: Paciente masculino de 32 años de edad, luego de inyección intramuscular de penicilina benzatínica presenta dolor intenso en área de inyección que se acompaña de lesiones eritematosas a nivel de abdomen, escroto y miembro inferior derecho además de presentar dolor, pareste-sia, palidez moteado eritematoso (livedo) y disminución de pulsos en dicha extremidad por lo que se diagnostica isquemia aguda (IA) que requirió tratamien-to fibrinolitico, entre otros fármacos. Conclusión: El síndrome de Nicolau es una condición iatrogénica que puede ser producida por inyección de múltiples medicamentos, puede presentar diferentes síntomas y signos como lesión neurológica, necrosis en área de irrigación de vasos afectados e incluso isquemia aguda. En este caso el manejo con rt-PA fue efectivo en tratar la isquemia. El conocimiento de este síndrome y sus complicaciones facilitaría su manejo2.Palabras claves: Síndrome Nicolau, bencilpenicilina, anticoagulante, rt-PA

ABSTRACT Introduction: Nicolau syndrome (NS), known as cutaneous embolism or livedoid dermatitis, is an adverse event due to the administration of intramuscular, intraarterial, subcutaneous and intraarticular injections associated with various drugs1. The entire pathogenesis of this syndrome is unknown, but it has been associated with vascular injury, arterial thrombosis, reflex spasm of the arteries, vascular occlusion due to microemboli, and inflammation. Clinical case: 32-year-old male. After an intramuscular injection of benzathine penicillin, the patient presented severe pain in the injection area accompanied by erythem-atous lesions at the level of the abdomen, scrotum, and right lower limb. In addition to that, the patient presented pain, paresthesia, and mottled paleness erythema (livedo). Moreover, the patient had a decreased pulse in the right limb, acute ischemia was diagnosed and required fibrinolitic treatment, among other drugs. Conclusion: Nicolau Syndrome, is an iatrogenic condition that is produced by injection of multiple drugs. It can produce different symptoms and signs from neurological injury, necrosis in the irrigation area of affected vessels and acute ischemia. rt-PA management in this case was effective in treating ischemia. It is essential to know about this syndrome and its complications. This would facilitate its management2.Keywords: Nicolau syndrome, benzylpenicillin, anticoagulant, rt-PA.

Nicolau Syndrome: A Rare Event Following Intramuscular Diclofenac

Nicolau Syndrome (Embolia cutis medicamentosa) is a rare complication occurs after parenteral administrationof drugs. It has been reported in association with intramuscular, intravenous or rarely subcutaneous injections.We hereby report a case of Nicolau Syndrome in a 60-year-old male patient.

Síndrome de Nicolau. Manejo conservador. Caso clínico / Nicolau syndrome, Conservative management: Clinical case

Introducción: el síndrome de Nicolau, embolia cutis o dermatitis livedoide, es una reacción adversa poco frecuente a la administración de inyección intramuscular, subcutánea o intraarticular de medicamentos, inicia con dolor intenso y eritema que evoluciona a lesión livedoide que se torna hemorrágica, progresa a necrosis isquémica de piel y tejidos más profundos. Caso clínico: niño de 7 meses de edad, luego de inyección intramuscular de metamizol sódico presenta llanto continuo, seguido de lesión purpúrica afectando espalda, glúteo, muslo y pierna derechos, evolucionando hasta cicatrización total en 18 semanas. Conclusión: el síndrome de Nicolau, condición iatrogénica por inyección de múltiples medicamentos, produce lesión necrótica en área de irrigación de vasos afectados. El conocimiento de este síndrome facilitaría su prevención, al igual que su diagnóstico y manejo tempranos

Introduction: Nicolau syndrome, embolism cutis or livedoid dermatitis, is a rare adverse reaction to the administration of intramuscular, subcutaneous or intra-articular injection of drugs, begins with intense pain and erythema that progresses to a livedoid lesion that becomes hemorrhagic, progresses to ischemic necrosis of skin and deeper tissues. Clinical case: A 7-month-old boy, after intramuscular injection of sodium metamizole, presented continuous crying followed by a purpuric lesion affecting the right back, gluteus, thigh and leg, evolving to total healing in 18 weeks. Conclusion: Nicolau Syndrome, iatrogenic condition by injection of multiple drugs, produces necrotic lesion in irrigated area of affected vessels. The knowledge of this syndrome would facilitate its prevention, as well as its early diagnosis and management.

Síndrome de Nicolau: A propósito de un caso / Nicolau syndrome: About a case

Se evaluó paciente femenino de 51 años, con antecedentes de diabetes mellitus tipo II e infecciones urinarias a repetición, procedente de la comunidad Mario Briceño Iragorry, quien acude al ambulatorio centro de especialidades "Los Grillitos", de la Corporación de Salud del Estado de Aragua - Venezuela, presentando lesión ulcerada a nivel de hemicadera izquierda, posterior a la colocación vía intramuscular de diclofenac sódico el 28/03/17, el que fue indicado por facultativo para tratar dolor por infección urinaria alta. Posteriormente, a las 24 horas presenta en la zona de la inyección una coloración violácea, induración y mucho dolor, motivo por el que acude nuevamente al facultativo. Se le realizó ecosonograma de partes blandas en región glútea izquierda, reportando imagen heterogénea a predominio hipoecoico con ecos internos de mediana intensidad, que genera reforzamiento posterior de 49x39 mm, con aproximadamente 30 cc de líquido, que correspondería a un proceso inflamatorio e infeccioso (absceso). Posteriormente a la evaluación, se indica antibiótico terapia a base de oxacilina 1 g cada 8 horas vía endovenosa por siete días, además 100 mg cada 12 horas vía oral de nitrofurantoína para el proceso infeccioso urinario, que el urocultivo indica ser sensible a la E. Coli. Al tercer día de la enfermedad actual, se le drena absceso con material purulento aproximadamente 20 cc y cura sucesiva por cinco días, evolucionando satisfactoriamente del proceso infeccioso de partes blandas e infección urinaria.

A 51-year-old female patient with a history of type II diabetes mellitus and recurrent urinary tract infections from the Mario Briceño Iragorry community, attended the outpatient clinic "Los Grillitos" of the health corporation of Aragua Venezuela, with an ulcerated lesion at the left hemi-hip level, following the intramuscular placement of diclofenac sodium on 03/28/17, which was indicated by facultative to treat pain due to high urinary tract infection, afterwards approximately 24 hours presents at the injection site a violet coloration, induration and a lot of pain, which is why she returned to facultative, she performed a soft-tissue echosonogram in the left gluteal region reporting a heterogeneous image to hypoechoic predominance with internal echoes of medium intensity that generates posterior reinforcement which measures 49x39 mm with approximately 30 cc of liquid that could correspond to an inflammatory and infectious process (abscess), post-evaluation is indicated antibiotic therapy based on oxacillin 1 g every 8 hours intravenous route for seven days plus 100 mg every 12 hours oral route of nitrofurantoin for the urinary infectious process that the urine culture indicates to be sensitive E. coli, the third day of illness is drained abscess purulent material approximately 20 cc and successive cure for five days. Satisfactory evolution of the infectious process of soft tissue and urinary tract infection.

Síndrome de Nicolau por la administración de la vacuna séxtuple intramuscular en un lactante de 6 meses / Nicolau syndrome induced by intramuscular injection of a hexavalent vaccine in a 6-month-old girl

El síndrome de Nicolau, también conocido como embolia cutis medicamentosa o dermatitis livedoide, es una reacción cutánea infrecuente, caracterizada por una necrosis de la piel y los tejidos blandos de aparición súbita luego de la aplicación intramuscular de algunas drogas. Presentamos a un bebé de 6 meses de edad que, al recibir la tercera dosis de la vacuna séxtuple intramuscular, desarrolló una lesión necrótica con reticulado violáceo periférico en el sitio de aplicación. Se destaca la importancia del diagnóstico precoz a fin de instaurar un adecuado tratamiento y seguimiento para evitar complicaciones secundarias a la isquemia.

Nicolau syndrome, also known as embolia cutis medicamentosa or livedo-like dermatitis, is a sudden tissue necrosis, a rare complication of intramuscular injection of some drugs. We report a case of a 6-month-old girl who received intramuscularly the third dose of hexavalent vaccine (DTaP-HVB-IPV/HIb), and immediately presented a livedoid lesion around the injection site, progressing to necrosis. We reinforce the importance of early diagnosis to perform a suitable treatment and clinical follow-up to avoid ischemic secondary complications.

Síndrome de Nicolau: a propósito de un caso / Nicolau Syndrome: About a case

Comunicamos una paciente femenina de 24 años de edad, natural y procedente de la localidad, quien consulta en el mes de enero de 2016 al Centro Integral de Especialidades “Los Grillitos”, CORPOSALUD. Municipio Mario Briceño Iragorry por presentar lesión ulcerosa a nivel de hemicadera derecha, cuya aparición fue posterior a la administración de medicamentos vía intramuscular (ampolla de amikacina). El tratamiento aplicado fue debido a una infección vaginal que presentó en el mes de septiembre 2015, cuyo cultivo resultó sensible a este antibiótico; comenzó a presentar un área endurecida color violáceo, hasta convertirse en una úlcera en el mes de diciembre 2015. Por este motivo, acude al médico quien indica ecosonograma de partes blandas (27/1/2016), informando: úlcera de 29 mm asociado a celulitis post infecciosa a administración medicamentosa, en hemicadera derecha y hematoma, organizado en hemicadera izquierda (0,25 cc); se realiza cultivo (27/1/2016) reportando presencia de Acinetobacter baumani complex sensible a la ciprofloxacina, la que se indica, observándose actualmente mejoría clínica de la lesión.

It is 24 years female patient age and naturally from the locality, who consults in January 2016 to Integral Center Specialty "The Grillitos" Corposalud. Municipio Mario Briceño Iragorry to present Injury ulcer type level right hemi hip whose appearance was after drug administration (vial amikacin) treatment applied due to a vaginal infection present in the month of September 2015 whose culture was sensitive to this antibiotic, he began to present purple colored hardened to become ulcerated area in December 2015. Which is why go to the doctor who said soft tissue sonography (01/27/2016) ulcer reporting 29 mm associated with post-infectious cellulitis to drug administration right hemi hip and a left organized hematoma (0.25 cc); culture (01.27.2016) is perform reporting presence of Acinetobacter baumani sensitive Ciprofloxacin treatment indicated Complex currently observed clinical improvement of the injury.

Tratamiento anticoagulante y vasodilatador para el síndrome de Nicolau tras la administración de una inyección de bencilpenicilina benzatínica intramuscular a un niño de cuatro años de edad / Anticoagulant and vasodilator therapy for Nicolau syndrome following intramuscular benzathine penicillin injection in a 4 year old boy

El síndrome de Nicolau (SN) es una complicación rara de la inyección de ciertos fármacos por vía intramuscular, intrarticular o subcutánea, que produce necrosis isquémica de la piel, las partes blandas y el tejido muscular circundante. La bencilpenicilina benzatínica es uno de los antibióticos más ampliamente empleados para las infecciones de las vías respiratorias altas y raramente se ha notificado que produzca SN. En este artículo presentamos el caso de un niño de sexo masculino de cuatro años de edad diagnosticado con SN tras la inyección de bencilpenicilina benzatínica tratado satisfactoriamente con heparina fraccionada (enoxaparina) y pentoxifilina. Los médicos deben estar atentos al uso innecesario de bencilpenicilina benzatínica para evitar las probables complicaciones.

Nicolau syndrome (NS) is a rare complication of intramuscular, intraarticular or subcutaneous injection of particular drugs leading to ischemic necrosis of the surrounding skin, soft tissue and muscular tissue. Benzathine penicilin one of the most widely used antibiotic for upper respiratory tract infections and has been rarely reported to cause NS. Here we describe a 4 year old boy with diagnosis of NS after the injection of benzathine penicillin who was successfuly treated with unfractionized heparin (enoxaparine) and pentoxifylline. The practitioners should pay attention for unnecessary use of benzathine penicillin to avoid from probable complications.

Post-injection embolia cutis medicamentosa - Nicolau Syndrome: case report and literature review / Embolia cutis medicamentosa pós-injeção - Síndrome de Nicolau: relato de caso e revisão de literatura

We report on the case of a 40-year-old male who was admitted to the clinic with a large ulcer on his left buttock, 3 days after an intramuscular benzathine penicillin injection. The patient was diagnosed with Nicolau syndrome, a rare vascular complication in which a lesion develops after intramuscular injection. Symptoms are intense pain at the injection site, erythema, and livedoid dermatitis, which leads to necrosis of skin, subcutaneous tissue and muscle tissue. It was described by Nicolau after intramuscular injections of bismuth salt for syphillis therapy. Nicolau syndrome is rare, but its symptoms are devastating and healthcare professionals must be aware of this clinical entity, since intramuscular injections are common procedures for administration of drugs.

Relatamos o caso de um homem de 40 anos apresentando uma grande úlcera na nádega esquerda 3 dias após receber injeção intramuscular de penicilina benzatina. O paciente foi diagnosticado com síndrome de Nicolau, uma rara complicação vascular com lesão após injeções intramusculares. Os sintomas incluem dor intensa no local da injeção, eritema e dermatite livedoide, o que leva a necrose da pele, do tecido subcutâneo e do tecido muscular. Foi descrita por Nicolau após injeções intramusculares de sal de bismuto para o tratamento de sífilis. A síndrome de Nicolau é incomum, mas seus sintomas são devastadores. Portanto, os profissionais de saúde precisam conhecer essa entidade clínica, uma vez que as injeções intramusculares são procedimentos comuns para a administração de drogas.

Nicolau Syndrome Following Intramuscular Diclofenac Injection / 대한정형외과학회잡지

Nicolau syndrome is a rare complication causing severe pain and tissue necrosis after intramuscular injection. In Korea, the Korea Dermatological Association has reported 12 cases, and some severe cases required surgical treatment. Most cases have been related to the administration of a variety of drugs, including nonsteroidal anti-inflammatory drugs, corticosteroids, and antibiotics. We present two patients who developed this complication, 1 case of typical Nicolau syndrome and 1 case of atypical Nicolau syndrome.

Successful Treatment of Nicolau Syndrome with Platelet Rich Plasma / 대한피부과학회지

Platelet rich plasma (PRP) therapy has been growing in popularity as a viable treatment alternative for a number of clinical applications and has a potential benefit for use in wound healing. The objective of the present study was to verify the effectiveness of PRP in the management of the refractory cutaneous ulcer associated with Nicolau syndrome. A 73-year-old woman with a diclofenac sodium intramuscular injection history in a local clinic presented with a severely painful acute necrotic ulcer on the right buttock. The ulcerative wound showed no improvement despite having conventional treatment for 1 month. After 3 weeks of the PRP treatment, the wound evolved favorably, with the alleviation of severe pain. It showed a size reduction of more than 80% after 4 months of regular follow up. The result demonstrated that PRP treatment could be an appropriate option for an extensive refractory ulceration associated with Nicolau syndrome.

Nicolau Syndrome after Intramuscular Injection: 3 Cases

Nicolau syndrome is a rare complication of intramuscular injection consisting of ischemic necrosis of skin, soft tissue, and muscular tissue that arises locoregionally. The characteristic pattern is pain around the injection site, developing into erythema, a livedoid dermatitis patch, and necrosis of the skin, subcutaneous fat, and muscle tissue. Three patients were injected with drugs (diclofenac sodium, ketoprofen, meperidine) for pain relief. Three patients complained of pain, and a skin lesion was observed, after which necrosis developed on their buttocks. Each patient underwent debridement and coverage. The wound healed uneventfully. We report three cases of Nicolau syndrome in the buttocks following diclofenac intramuscular injection.

Nicolau Syndrome in Patient Following Diclofenac Administration: A Case Report

Nicolau syndrome is a rare adverse reaction to a variety of intra-muscular drug preparations. The typical presentation is pain around the injection site soon after injection, followed by erythema, livedoid patch, hemorrhagic patch, and finally, necrosis of skin, subcutaneous fat, and muscle tissue. The phenomenon has been related to the administration of a variety of drugs, including non-steroidal anti-inflammatory drugs, corticosteroids, and penicillin. We report a case with typical features associated with diclofenac injection for pain control in a patient who had undergone bilateral total knee arthroplasty.

Nicolau Syndrome in Which Split-thickness Skin Graft Was Required for Reconstruction / 대한피부과학회지

Nicolau syndrome is a rare adverse reaction and characterized by the acute onset of necrosis of the skin and soft tissue following intramuscular drug injection. Conservative treatments with dressings, debridement, and pain control are the mainstay of therapy. Surgical intervention such as skin graft is rarely required. We report a case of 21-year-old man with this syndrome on the right buttock after an intramuscular injection of diclofenac in which skin graft was necessary. The lesion eventually required debridements and split-thickness skin graft for reconstruction because it was very extensive and not successfully treated by the conservative method for four months.

Embolia Cutis Medicamentosa Following Intramuscular Injection of Diclofenac / 대한피부과학회지

Nicolau syndrome or embolia cutis medicamentosa is a rare complication of a still largely unidentified pathogenesis at the site of intramuscular injections of various drugs. It is characterized by development of an acute, severe pain around the injection site followed by a localized erythema, a reticular rash, a hemorrhagic patch and varying degrees of tissue damage. The disease outcomes vary from atrophic ulcers and pigmentation to lower limb paralysis and limb amputation. We describe a 34-year-old woman with the diagnosis of this syndrome after she received an intramuscular diclofenac-beta-dimethyl-aminoethanol injection to the lateral aspect of the right upper buttock. The patient was treated by surgical debridement with concomitant primary closure.

Acidente por injeção medicamentosa no músculo deltoide: lesões locais e à distância, revisão de 32 casos / Intramuscular accident with drug injection in the deltoid muscle: local and distant lesions, review of 32 cases

Análise de 32 casos de acidentes por injeção, na maioria das vezes, de substâncias oleosas no músculo deltoide. Os acidentes caracterizaram-se por dor e reações tróficas locais. Em muitos casos, simultaneamente, ocorreram distúrbios isquêmicos nas regiões escapular, peitoral e, especialmente, na extremidade do membro. Presume-se que esse complexo lesional é gerado: 1) pela ação lesiva do medicamento nas terminações nervosas, nos tecidos moles e perivasais; e/ou 2) pela entrada fortuita da substância no interior dos vasos, produzindo embolia e/ou endotelite trombosante; e/ou 3) pelo despertar de fenômenos vasomotores. As lesões da mão, geralmente, foram mais graves que as lesões deltoidianas, com a eventual perda de dedos, espontânea ou cirúrgica. Os diversos quadros clínicos do acidente foram semelhantes, mas algumas características lesionais permitiram identificar mecanismos fisiopatogênicos peculiares, o que tem significado conceitual e terapêutico.

Analysis of 32 cases of accidental injection of oily suspension (in most cases) into the deltoid muscle is reported. Pain and local ulcers characterized the accidents. In many cases, simultaneous ischemic disorders were observed in the scapular and pectoral regions and especially in the end of the upper limb. It is presumed that this complex lesion was caused by 1) the harmful action of the medication on nervous terminations, soft and perivascular tissues; and/or 2) occasional entrance of the substance into blood vessels, causing embolism and/or thrombotic endothelitis; and/or 3) vasomotor phenomena. Hand injuries were generally more severe than injuries in the deltoid region, with occasional spontaneous or surgical loss of fingers. Clinical statuses were similar, though some lesions had features, which allowed identification of peculiar physiopathogenic mechanisms, with conceptual and therapeutic significance.

A Case of Nicolau Syndrome Treated with Non-steroidal Anti-inflammatory Drug Injection Therapy / 대한피부과학회지

Nicolau syndrome, also known as livedoid dermatitis or embolia cutis medicamentosa, is a rare cutaneous adverse drug reaction characterized by the acute onset of cutaneous and soft-tissue necrosis following intramuscular drug injection. The typical presentation is pain around the injection site, developing into erythema, a livedoid patch, and necrosis of the skin, subcutaneous fat, and muscle tissue. We report a 72-year-old man who presented with a painful, erythematous patch on his left buttock. The patient was treated with non-steroidal anti-inflammatory drug (diclofenac sodium) injection.

A Case of Nicolau Syndrome Treated by Surgical Excision / 대한피부과학회지

Nicolau syndrome or embolia cutis medicamentosa is an acute necrotic condition of skin that follows intramuscular injection of drugs. A 36-year-old man developed a painful, purpuric and erythematous patch on his left buttock following an intramuscular injection of diclofenac sodium. Histologically, the patch lesion displayed epidermal necrosis, dermal degeneration, and vascular thrombosis. We report a rare case of Nicolau syndrome following intramuscular injection of diclofenac sodium. In our case, the patient was successfully treated by surgical excision with primary closure.

A Case of Nicolau Syndrome / 대한피부과학회지

Nicolau syndrome is a rare adverse reaction of the skin at the site of intramuscular drug injection, and has largely unidentified pathogenesis. It consists of the development of an acute, severe pain and a localized erythematous rash during intramuscular injection leading to cutaneous, subcutaneous and even muscular necrosis. We report a case of a 55-year-old woman who presented with a painful skin necrosis in her buttocks following an intramuscular diclofenac-beta-dimethyl-aminoethanol injection.

A Case of Nicolau Syndrome Due to Diclofenac Sodium / 대한피부과학회지

Nicolau syndrome is defined as local cutaneous and sometimes muscular necrosis observed at the injection site of intramuscular preparations. It is characterized by severe pain immediately after the injection and variable degrees of skin necrosis. The only treatment is conservative. A 46-year-old man presented with painful skin necrosis on his buttock after the injection of diclofenac sodium. Histopathologic examination showed necrosis of the epidermis and upper 2/3 of the dermis. The lesion was treated conservatively with topical antibiotic ointment. We report a rare case of Nicolau syndrome due to diclofenac sodium.