Intramuscular diclofenac is a cause of Nicolau syndrome in obese women: An observational study of consecutive ten patients.

Nicolau syndrome is a skin and underlying tissue necrosis resulting from vascular occlusion after various injections of certain drugs. Intramuscular injections are the most common cause but it may occur after other types of parenteral interventions. There are many medications reported as causative factors inducing Nicolau syndrome including penicillin, nonsteroidal anti-inflammatory drugs, corticosteroids, local anesthetics, and several others. We present an observational study of diclofenac induced Nicolau syndrome.

[Suprapubic Nicolau syndrome following subcutaneous injection of glatiramer acetate]. / Dermite livédoïde de Nicolau sus-pubienne après injections sous-cutanées d'acétate de glatiramère.

BACKGROUND: Subcutaneous glatiramer acetate, commercialized under the name of Copaxone®, is licensed for the treatment of relapsing multiple sclerosis. Its major adverse effects are skin reactions at the injection site. Nicolau syndrome is a rare but serious iatrogenic accident. Herein we report a case seen in a setting of change of dosage and administration rate of Copaxone®. PATIENTS AND METHODS: A 64-year-old woman, treated since 2010 with daily sub-cutaneous injections of Copaxone® 20mg/L, reported the appearance of a painful, indurated and erythematous plaque in the suprapubic area following changeover to 40mg/mL injections three times weekly. The suprapubic injections were continued and ugly greyish spots with stellate purpuric borders appeared. Fournier gangrene was ruled out by means of a soft tissue scan. DISCUSSION: We report this latest case of Nicolau syndrome to alert readers to the non-exceptional nature of this complication associated with use of glatiramer acetate, particularly at a dosage of 40mg/L injections three times weekly. In our case, onset of Nicolau syndrome appears to have been favored by continued injection in areas already showing inflammation. Re-injection of the drug in these areas should thus be proscribed.

[Nicolau livedoid dermatitis with severe neurological involvement in a child]. / Dermite livédoïde de Nicolau avec atteinte neurologique sévère chez un enfant.

BACKGROUND: Nicolau syndrome is a rare condition consisting in tissue ischemia and necrosis following intramuscular, intra-articular or subcutaneous injection. PATIENTS AND METHODS: Immediately after gluteal intramuscular injection of benzathine-penicillin, a 10-year-old male child presented an extensive painful violaceous lesion on the left buttock associated with urinary incontinence and left lower-limb paresis. Additional underlying muscular damage was supported by high serum levels of creatine kinase and lactate dehydrogenase. Treatment was based on fluid expansion, intravenous steroids and anticoagulants, resulting in improvement of cutaneous and muscular lesions. Improvement in terms of neurological dysfunction was obtained after regular neuromuscular rehabilitation. DISCUSSION: This case underlines the need to prevent Nicolau syndrome by means of compliance with the technical recommendations for intramuscular injections.

Nicolau syndrome and localized panniculitis: a report of dual diagnoses with an emphasis on morphea profunda-like changes following injection with glatiramer acetate.

Glatiramer acetate, given as a 40 mg subcutaneous injection thrice weekly, was recently approved by the FDA based on data suggesting better compliance and a more favorable side effect profile compared to lower dose, daily dosing. The most commonly reported adverse events are transient injection site reactions involving redness and pain at the site; however, more pronounced panniculitis and lipoatrophy have also been reported. Here, we present the case of a 51-year-old female treated with higher dose glatiramer acetate who presented with a cutaneous injection site reaction consistent with Nicolau syndrome. The excised specimen revealed typical glatiramer acetate-associated panniculitis, alongside subcutaneous sclerosis. This case shows the spectrum of cutaneous complications possible with glatiramer acetate injections, the finding of sclerosis being relatively infrequently reported. Given the relatively short duration of trials leading to FDA approval of thrice weekly dosing of glatiramer acetate, clinicians should perform careful clinical and histopathological evaluation and reporting of patients who experience injection site reactions.

Nicolau syndrome due to hyaluronic acid injections.

Six cases of vascular compromise after hyaluronic injection are reported. Clinical symptoms realized a Nicolau syndrome, which is characterized by immediate pain, livedoid pattern and a few days later by the appearance of scabs and skin necrosis. This type of complication is rare, but may be dramatic and injectors must be aware of that. A thorough knowledge of facial anatomy is mandatory to avoid the risky facial areas. The use of a flexible cannula instead of a sharp needle has much less risk of hurting vessels and must be preferred. The support of the patient is discussed and a treatment protocol is proposed.

Complications of injectable fillers, part 2: vascular complications.

Accidental intra-arterial filler injection may cause significant tissue injury and necrosis. Hyaluronic acid (HA) fillers, currently the most popular, are the focus of this article, which highlights complications and their symptoms, risk factors, and possible treatment strategies. Although ischemic events do happen and are therefore important to discuss, they seem to be exceptionally rare and represent a small percentage of complications in individual clinical practices. However, the true incidence of this complication is unknown because of underreporting by clinicians. Typical clinical findings include skin blanching, livedo reticularis, slow capillary refill, and dusky blue-red discoloration, followed a few days later by blister formation and finally tissue slough. Mainstays of treatment (apart from avoidance by meticulous technique) are prompt recognition, immediate treatment with hyaluronidase, topical nitropaste under occlusion, oral acetylsalicylic acid (aspirin), warm compresses, and vigorous massage. Secondary lines of treatment may involve intra-arterial hyaluronidase, hyperbaric oxygen therapy, and ancillary vasodilating agents such as prostaglandin E1. Emergency preparedness (a "filler crash cart") is emphasized, since early intervention is likely to significantly reduce morbidity. A clinical summary chart is provided, organized by complication presentation.

Nicolau Syndrome with Severe Facial Ischemic Necrosis after Endodontic Treatment: A Case Report.

Nicolau syndrome (NS) is a rare complication resulting from intramuscular injections. It is characterized by severe pain at the injection site and the development of purplish discoloration. Only a limited number of case reports have been published documenting the adverse effects associated with the injection of calcium hydroxide (CH) beyond the apex during endodontic treatment. Here, we present the case of a 16-year-old female with NS after the injection of CH during the root canal treatment. The radiography examination revealed distal occlusion of the right maxillary and facial arteries. This caused a substantial area of skin necrosis to develop on the patient's face, resulting in permanent scarring. NS is associated with the displacement of CH beyond the apex. To minimize the risk of NS, dentists should exercise caution by avoiding forced injection of CH during treatment, particularly when the root canal is actively bleeding.

Nicolau Syndrome Following Glatiramer Injection in a Middle-Aged Woman.

Nicolau syndrome is a rare adverse reaction that can occur in the setting of intramuscular, intravenous, and subcutaneous injections. Proper diagnosis and management are critical to avoid complications including abscesses, muscular atrophy, and necrotizing fasciitis. Here, we report a 55-year-old female with multiple sclerosis who presented to our clinic following a subcutaneous injection of 40mg of glatiramer. She immediately noted a sharp pain and erythema, which developed into a purple discoloration, became purulent, and eventually necrosed. The patient's wound was debrided, and she was advised to clean the wound with soap and water, apply topical mupirocin, and change dressings twice daily. She continued to receive appropriate follow-up care with weekly to bi-weekly debridement with excellent resolution.

Nicolau Syndrome Secondary to Subcutaneous Glatiramer Acetate Injection.

Nicolau syndrome, also known as embolia cutis medicamentosa, is a rare complication of injectable drugs. Patients present with pain at injection site, followed by swelling, erythema, purple, hemorrhagic patches and lastly ulcer formation. A variety of intramuscular agents have been implicated as responsible. We report a case of a 26-year-old woman with a history of a purple lesion on her thigh who was diagnosed with Nicolau syndrome due to subcutaneous administration of glatiramer acetate. The patient was followed up with topical mupirocin. On follow-up, although the patient stated that she continued using glatiramer acetate, no new lesions appeared and the existing lesion continued to shrink. Nicolau syndrome seems to have an unpredictable and unavoidable course. This case suggests that physicians should have a high index of suspicion for the presence of Nicolau syndrome in patients presenting with necrotic or ulcerative lesions with a history of using injectable drugs.

Embolia cutis Medicamentosa (Nicolau syndrome): case series.

Introduction: Embolia cutis medicamentosa or Nicolau syndrome is a rare drug reaction associated with the administration of various injectable medications. The pathogenesis of the disease is unknown, though intra and periarterial injection of the drug is a possible cause. The aim of this study was to describe and analyze the clinical characteristics of Nicolau syndrome in patients examined in daily dermatological practice. Methods: We performed a retrospective chart review, between January 2011 and December 2020, in patients diagnosed with Nicolau syndrome, from the cases of a private dermatology medical office in Târgu Mureș, Romania. Results: During the 10-year period, 7 patients were diagnosed with Nicolau syndrome. Of these, 4 (57%) patients were males and 3 (43%) were females, The male to female ratio was 1.33. The median age was 64 (interquartile range, IQR, 62-71), with the youngest patient being diagnosed at age 61 and the oldest at age 74. Regarding the drugs classes that caused Nicolau syndrome, these were intravenous antibiotics in 57%, and non-steroidal anti-inflammatory drugs in 43% of cases. Conclusion: All patients healed in a period of 6 to 8 weeks. No complications occurred. In conclusion, Nicolau syndrome is a rare side effect of injectable drug administration.

Nicolau syndrome following Intramuscular Diclofenac Injection: a case report and review of the literature.

Nicolau syndrome (NS), also referred as embolia cutis medicamentosa and livedo-like dermatitis, is an uncommon complication followed by drugs administered intramuscularly, intraarticularly or subcutaneously. In this case report we present a case of a 65-year-old lady who had a single dose of diclofenac sodium as an intramuscular injection in her left buttock due to back pain that led to developing what known as NS. She was treated with surgical debridement, drain insertion and skin approximation with antibiotics for 2 weeks with daily sterile dressing. The wound healed completely with scarring. NS is a preventable outcome, thus, proper procedures and precautions should be taken during intramuscular medication administration. Healthcare providers should avoid unnecessary injections, be familiar with the complication and consider it as a potential diagnosis for severe localized pain after any injection.

Nicolau syndrome associated with fluphenazine depot: A case report.

Nicolau syndrome is a rare condition characterized by severe pain at the site of injection, leading to ulceration and necrosis of the local tissues. Its presentation is usually acute. Nicolau syndrome is commonly seen in patients after intramuscular, intra-articular, or subcutaneous injections of non-steroidal anti-inflammatory drugs, antiepileptics, antipsychotics, antibiotics, antihistamines, and corticosteroids. Immediate diagnosis and management of this syndrome are of great importance. We herein report a rare presentation of Nicolau syndrome in a 36-year-old married male who suffered from paranoid schizophrenia for the past 3 years. The patient presented with dull pain, mild swelling, and necrotic ulceration over the injection site after receiving intramuscular fluphenazine. The patient underwent wound debridement and was given prophylactic antibiotics. Despite a wide range of therapeutic options for the management of Nicolau syndrome described in the literature, there exist limited guidelines for its management.

[Nicolau syndrome]. / Síndrome de Nicolau.

Nicolau syndrome is a rare complication of the parenteral application of various drugs. It is characterized 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.

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.

Extensive Deep Tissue Involvement in Nicolau Syndrome and Below-Knee Amputation: A Case Report and Literature Review.

Nicolau syndrome (NS) is a rare cutaneous drug reaction in response to injections administered via any route. Based on the available studies in the medical literature, NS presents as skin and subcutaneous fat necrosis, and typically, it does not cause severe complications such as acute limb ischemia or death. In this study, we report the case of a 6-year-old boy who received an intramuscular injection of benzathine penicillin G for the treatment of bacterial pharyngitis, and subsequently developed a severe case of NS, which eventually led to below-knee amputation of the right lower limb. Although a few approaches have been suggested for the management of NS, they might not be effective under certain circumstances. Early detection, close monitoring, and consistent interventions, such as surgical fasciotomy and debridement procedures, might be necessary in severe cases of NS.

Nicolau Syndrome after Endodontic Treatment: A Case Report.

Calcium hydroxide has been used successfully in root canal therapy for many years. However, it can cause serious damage if it is inadvertently displaced into surrounding vital structures, resulting in thrombosis if displaced into blood vessels, damaging connective tissue, and causing skin necrosis. These adverse reactions are known as Nicolau syndrome (NS) or embolia cutis medicamentosa. Very few case reports have been published about these adverse effects of injecting calcium hydroxide beyond the apex during root canal therapy. A 16-year-old female patient was referred to the endodontic department of Hamad Dental Center for assessment after treatment by the maxillofacial surgery department for swelling and tissue necrosis that occurred after endodontic treatment in another clinic. When the patient initially attended the maxillofacial surgery department, she presented with swelling on the left side in the region of the maxillary left first permanent molar. On examination, there was a change in the color of the skin of the left cheek in that area along with some reported paralysis of the left side of her lips. Analgesics and antibiotics had already been prescribed at the referring clinic. Two weeks later, the patient developed a necrotic patch of skin on the same area. Subsequent evaluation at the endodontic department of Hamad Dental Center led to a diagnosis of NS. NS is a very rare iatrogenic condition. Displacing calcium hydroxide beyond the apex might increase the chance of NS. Clinicians should avoid overinstrumentation and forced injection of calcium hydroxide to prevent NS.

Embolia Cutis Medicamentosa (Nicolau Syndrome) Secondary to Intramuscular Fulvestrant Injection: A Case Report.

PURPOSE: A case of embolia cutis medicamentosa (Nicolau syndrome) in a patient receiving monthly intramuscular fulvestrant injections is presented. SUMMARY: An 85-year-old woman receiving monthly fulvestrant injections in the outpatient setting developed a necrotic lesion at the fulvestrant injection site on her right buttock. Her medical history is notable for metastatic breast cancer with bone metastases. Prior to developing the necrotic lesion, the patient was receiving monthly fulvestrant injections for 6 years. Other potential causes such as infection and pressure necrosis were ruled out clinically. After 185 days of wound care involving multiple surgical debridements, topical therapy, and frequent follow-up appointments, the patient's wound resolved with 100% epithelialization. Nicolau syndrome has been reported with other non-vesicant, injectable medications such as antibiotics and corticosteroids; however, it has not been previously reported with fulvestrant. CONCLUSION: Nicolau syndrome developed in the right buttock of a patient with metastatic breast cancer following an intramuscular fulvestrant injection. Healthcare practitioners need to be cognizant of this adverse effect with intramuscular injections in order to recognize and refer patients for wound care evaluation early in the evolution of this syndrome. Proper injection technique is recommended to reduce the risk of this idiopathic adverse effect.

Nicolau syndrome caused by Glatiramer.

Injection-site reactions to glatiramer are common and include erythema, pruritus, pain, or induration. Additionally, the present systematic review of the literature documents 20 cases of Nicolau syndrome following glatiramer, a rare but potentially severe skin reaction. Abdomen and thighs are the most frequently affected areas (80% of reported cases), and permanent skin damage has been observed in 30% of cases. Recurrences are rare (<10%).

Hyperbaric oxygen treatment in a rare complication of intramuscular injection: four cases of Nicolau syndrome.

Intramuscular injections are one of the most common clinical procedures. The objectives of this case series are to analyse the role, timing and efficacy of hyperbaric oxygen treatment (HBOT) in the management of Nicolau syndrome (NS), an extremely rare complication of this common intervention. Clinical, demographic, laboratory and microbiological data extraction were performed through retrospective analysis of the medical records of all patients with NS who were referred for HBOT over a 10-year period with wounds, ischaemia, infection or necrosis at the injection site following drug injection; four patients with NS were included. All injections were made via the intramuscular route; three adult cases followed a non-steroidal anti-inflammatory drug, diclofenac sodium and one in a child followed penicillin injection. The time between diagnosis/injection and HBOT ranged from five to 33 days. NS can develop despite all preventive measures based on injection technique guidelines. HBOT appeared beneficial to healing of NS when administered with other therapeutic approaches. Due to the missing pieces of the puzzle in pathogenesis, NS is rarely completely reversible; keeping the awareness high for undesirable complications stands out as the most effective approach.

Case Reports of Heroin Injection Site Necrosis: A Novel Antecedent of Nicolau Syndrome.

Heroin injection-site necrosis (HISN) is a novel and poorly understood complication of intravenous drug abuse (IVDA). We present three cases of HISN that were evaluated and treated in Charleston, West Virginia, in 2019 and 2020. The documented cases show similarities involving patient care, follow-up, clinical progression, patient demographic, and dermatologic sequelae. We discuss these similarities, provide clinical recommendations, review proposed etiologies of HISN, and introduce Nicolau syndrome as a potential mechanism.