Nicolau syndrome, embolia cutis medicamentosa, an iatrogenic consequence of intramuscular injections: a case report and literature review with a synthesis of case studies
- MOJ Clinical & Medical Case Reports
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Jacob J Nasser, BS, DPM, Ahmad Saad, BS, DPM, Joseph A Saracco, BS, DPM
Abstract
Introduction: Nicolau syndrome (NS) was first described in 1924 by Freudental and
Nicolau in a syphilis patient that was treated with injections of bismuth. NS is characterized
by skin necrosis secondary to vascular occlusion caused by intramuscular drug injections.
Recent literature has shown that livedoid dermatitis and embolia cutis medicamentosa are
symptoms of Nicolau syndrome, which develop into a hemorrhagic bullae. The bullae then
progress to necrotic ulcerations that may lead to infection, ischemia and even limb loss.
Purpose: To describe Nicolau Syndrome and the life-altering effects it can have on patients.
Methodology & procedure: A systematic review of studies published in the Medline
database from January 2018 through July 2022 was conducted to identify articles that
evaluated the causes and symptoms of Nicolau Syndrome. The systematic review was
conducted following the PRISMA guidelines with an inclusion criteria of Nicolau
syndrome diagnosis with no exclusion criteria. Summary tables were generated from the
included studies for case specific indications of the intramuscular injection(s), sequence of
symptomology, any treatment(s) administered and outcome of the syndrome for each case.
Results: 36 Cases of NS were reported in the last 5 years from our literature search. The
PRISMA flow diagram will show the reported cases, sex, age, what the injection consisted
of, the number of recorded injections in the past 3 and 5 years and treatments (if rendered)
with outcomes, if data is available. Spontaneous resolution was seen in a few select cases,
although most ended up with some type of debridement/amputation.
Case description: Our patient was a 47-year-old female with a long history of corticosteroid
injections including the neck, back and upper extremities, with her most recent injection for
plantar fasciitis of her left foot. After the injection she was prescribed oral Cephalexin that
she took for two days before presenting to the emergency department with a small lesion
that had dermatological changes consistent with bruising/contusion. Over the course of the
month, the patient’s lesion continued to deteriorate despite several treatment attempts from
a multidisciplinary limb salvage team. Ultimately, she underwent a left lower extremity
below-knee amputation.
Discussion: Use of intramuscular injections across all fields of medicine is commonplace
and it would appear physicians overlook or are unaware of the risks of Nicolau Syndrome.
Although the pathogenesis is still debated, researchers have theorized that sympathetic
activation results in vasoconstriction, embolic occlusion of microcirculation, and
prostaglandin synthesis inhibition.
Keywords
Nicolau syndrome, pathophysiology, perivascular injection, penicillin
