Upper limb gangrene following intramuscular diclofenac: a rare side effect

A Case of Fatal Non-Clostridial Gas Gangrene Following Intramuscular Injection: A Diagnostic Challenge and Dilemma at Autopsy

Introduction

Gas Gangrene following intramuscular injection is a rare but serious condition that can lead to morbidity and mortality. This case conveys a severe and fatal complication following intramuscular injections of diclofenac and vitamin B12 in a diabetic patient.

Case Report

The patient developed pain and swelling in the left buttock after the injection of vitamin B12 and Diclofenac one on each buttock which worsened over time. He was diagnosed with gas gangrene when he presented to the emergency department. The blood culture identified Klebsiella pneumonia. The patient's condition rapidly deteriorated, leading to sepsis and acute kidney injury. Despite intensive care management, the patient succumbed five days after admission. At autopsy, gas gangrene of the left lower limb was evident on external examination. Histopathological examination confirmed the acute tubular damage in the kidney and the postmortem blood culture also grew Klebsiella pneumonia and Enterobacter cloacae. The cause of death was determined to be acute tubular necrosis as a result of sepsis due to non-clostridial gas gangrene.

Conclusion

This instance of gas gangrene following trivial trauma poses a challenge for the forensic pathologist in establishing the causal association and in determining the causative organism. These are important when medical/surgical intervention is in question to be the cause of a fatal infection like gas gangrene. Ante-mortem/postmortem blood culture can aid in defining the causative organism of gas gangrene but the causal association with the alleged trauma/insult is still a challenge at autopsy. This case report addresses and tries to overcome the diagnostic challenges and dilemmas at autopsy in a case of gas gangrene.

Pentazocine with rectal diclofenac versus pentazocine alone for pain relief following caesarean delivery in Enugu, Nigeria: A randomized controlled trial

Objective

To measure postoperative pain relief following the use of rectal diclofenac combined with intramuscular pentazocine compared with intramuscular pentazocine alone in patients undergoing a caesarean delivery.

Methods

This single-blind randomized controlled trial enrolled pregnant women that had a caesarean section at the Enugu State University of Science and Technology Teaching Hospital, Enugu, Nigeria. Study participants were randomized to receive either 100 mg of rectal diclofenac given every 12 h plus 30 mg of intramuscular pentazocine given every 6 h (group A) or 60 mg of intramuscular pentazocine given every 6 h (group B). The primary outcome was the level of pain as measured using a visual analogue scale. The secondary outcomes were the level of satisfaction with pain relief and need for rescue analgesia.

Results

A total of 200 participants were randomized equally into the two groups. Participants in group A had significantly better pain control and satisfaction over the 48 h after surgery compared with group B. Significantly more of group B required rescue analgesia for breakthrough pain compared with group A.

Conclusion

Rectal diclofenac combined with intramuscular pentazocine was significantly better at controlling pain compared with pentazocine alone in the first 48 h following caesarean section.

Trial registration number: PACTR202107706925314 at www.pactr.org on 28 July 2021.

Nicolau syndrome caused by non-steroidal anti-inflammatory drugs: Systematic literature review

AIM

Intramuscular or, more rarely, local drug injection is occasionally followed by immediate local pain, livedoid skin lesions and, some days later, the development of ischemic lesions. This very uncommon but potentially severe reaction, termed Nicolau syndrome, is traditionally associated with bismuth and β-lactam antimicrobials. The aim of this report was to review the literature associating Nicolau syndrome with the administration of non-steroidal anti-inflammatory drugs.

METHODS

The National Library, Excerpta Medica, Web of Science and Cochrane library databases were used.

RESULTS

Sixty-two cases (40 females and 22 males aged from 13 to 81, median 57 years) of Nicolau syndrome were published after 1992. Fifty-three cases occurred after diclofenac. The remaining nine cases were associated with ketoprofen (N = 2), ketorolac (N = 2), phenylbutazone (N = 2), etofenamate (N = 1), ibuprofen (N = 1) and piroxicam (N = 1).

CONCLUSION

Although Nicolau syndrome is extremely uncommon, physicians must be aware of this complication after intramuscular administration of non-steroidal anti-inflammatory drugs and should avoid unnecessary injections.

A misplaced intramuscular injection and limb-threatening ischemia

Femoral artery thrombosis is a rare complication of intramuscular (IM) injection in children. A 12-month-old boy presented with right lower limb ischemia and digital gangrene 3 days after an injection of ceftriaxone administered to his medial aspect of the right thigh. Successful thrombolysis and partial limb salvage was possible with enoxaparin despite a late presentation. Unnecessary and unsafe IM injection in community practice might lead to such devastating outcome which should be avoided.