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Ata YM, Ahmed MB, Al-Mohannadi FS, Al-Jassim FA, Shabbir A. Nicolau syndrome following Intramuscular Diclofenac Injection: a case report and review of the literature. J Surg Case Rep 2023; 2023:rjad224. [PMID: 37124574 PMCID: PMC10147548 DOI: 10.1093/jscr/rjad224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/04/2023] [Indexed: 05/02/2023] Open
Abstract
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.
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Affiliation(s)
- Yaser M Ata
- Correspondence address. Urology Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar. Tel: +97433810427; E-mail:
| | - Mohamed B Ahmed
- Plastic Surgery Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Fatima S Al-Mohannadi
- Plastic Surgery Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Fatima A Al-Jassim
- Urology Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Azhar Shabbir
- Acute Care Surgery Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
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Esme P, Gahramanov I, Akıncıoglu E, Akoglu G. Nicolau syndrome following subcutaneous glatiramer acetate injection: A case report and review of the literature. Indian J Pharmacol 2022; 53:489-492. [PMID: 34975138 PMCID: PMC8764978 DOI: 10.4103/ijp.ijp_166_21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Nicolau syndrome is a rare serious drug reaction associated with the administering various injectable medications. It is often characterized by an acute and severe pain accompanying erythema that tends to rapidly evolve into the livedoid reticular or hemorrhagic patches and less commonly to ulcers and skin necrosis. Herein, we report a 34-year-old woman who presented with painful, tender discoloration over her abdominal skin following subcutaneous glatiramer acetate injection. Since the patient was diagnosed with multiple sclerosis 18 months ago, she had been on treatment with subcutaneous glatiramer acetate injections thrice weekly. The patient was diagnosed with Nicolau syndrome clinically and histopathologically. After 15-day treatment with topical betamethasone valerate and mucopolysaccharide polysulfate cream twice daily, the lesion completely regressed with only minimal hypopigmented irregular scarring. Nicolau syndrome should be considered in patients with severe pain, tenderness, and redness localized at the injection site following glatiramer subacetate.
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Affiliation(s)
- Pelin Esme
- Department of Dermatology and Venereology, University of Health Sciences, Gulhane Training and Research Hospital, Ankara, Turkey
| | - Irfan Gahramanov
- Department of Dermatology and Venereology, University of Health Sciences, Gulhane Training and Research Hospital, Ankara, Turkey
| | - Egemen Akıncıoglu
- Department of Pathology, University of Health Sciences, Gulhane Training and Research Hospital, Ankara, Turkey
| | - Gulsen Akoglu
- Department of Dermatology and Venereology, University of Health Sciences, Gulhane Training and Research Hospital, Ankara, Turkey
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Ciprian S, Lava SAG, Milani GP, Bianchetti MG, Consolascio D, Lardelli PF. Nicolau syndrome caused by Glatiramer. Mult Scler Relat Disord 2022; 57:103365. [PMID: 35158471 DOI: 10.1016/j.msard.2021.103365] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 10/17/2021] [Accepted: 10/30/2021] [Indexed: 11/19/2022]
Abstract
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%).
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Affiliation(s)
- Sandro Ciprian
- Pediatric Cardiology Unit, Department of Pediatrics, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Sebastiano A G Lava
- Pediatric Cardiology Unit, Department of Pediatrics, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland.
| | - Gregorio P Milani
- Pediatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Mario G Bianchetti
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland; Pediatric Institute of Southern Switzerland EOC, Ospedale San Giovanni, Bellinzona, Switzerland
| | - Danilo Consolascio
- Family Medicine Institute, Università della Svizzera Italiana, Lugano, Switzerland
| | - Pietro F Lardelli
- Family Medicine Institute, Università della Svizzera Italiana, Lugano, Switzerland
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Vlahova L, Kretschmer L, Schön MP, Mössner R. Embolia Cutis Medicamentosa after Subcutaneous Injection with Glatiramer Acetate. Case Rep Dermatol 2021; 13:114-120. [PMID: 33790754 PMCID: PMC7989669 DOI: 10.1159/000510017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 07/08/2020] [Indexed: 11/19/2022] Open
Abstract
Embolia cutis medicamentosa (ECM) is a rare and unpredictable injection site reaction, occurring after intramuscular, subcutaneous, and even after intraarticular injection of various drugs. We report a very rare case of necrotizing ECM after injection of glatiramer acetate for multiple sclerosis, include a photo documentation over the entire disease course, and discuss hypotheses as to etiology and treatment.
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Affiliation(s)
- Lyubomira Vlahova
- Department of Dermatology, Venereology and Allergology, University Medical Center Göttingen, Göttingen, Germany
| | - Lutz Kretschmer
- Department of Dermatology, Venereology and Allergology, University Medical Center Göttingen, Göttingen, Germany
| | - Michael P Schön
- Department of Dermatology, Venereology and Allergology, University Medical Center Göttingen, Göttingen, Germany
| | - Rotraut Mössner
- Department of Dermatology, Venereology and Allergology, University Medical Center Göttingen, Göttingen, Germany
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Shelley BP, Prasad P, Manjunath MM, Chakraborti S. Hyperacute Paraplegia and Neurovascular (Immuno Vasculotoxic) Catastrophe of Nicolau Syndrome: Primum Non nocere. Ann Indian Acad Neurol 2019; 22:104-108. [PMID: 30692770 PMCID: PMC6327711 DOI: 10.4103/aian.aian_298_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
A case of Nicolau syndrome (NS) in a 36-year-old adult taking an unusual and devastating hyperacute irreversible paraplegia after an intramuscular injection of benzathine penicillin as a part of routine chemoprophylaxis of her rheumatic heart disease is reported. Although this syndrome is a considerably rare, iatrogenic and underappreciated dermatologic entity, we reiterate in this report, its extracutaneous systemic potential for a catastrophic neurovascular phenomenon and morbidity as well as its possible preventive measures. The apoplectiform onset of T10 flaccid areflexic paraplegia, with the cutaneous hallmark of "embolia cutis medicamentosa" was corroborated by magnetic resonance imaging evidence of centromedullary complete cord involvement from T10 to conus medullaris. Combination therapy with pulse methylprednisolone, low-molecular-weight heparin, and pentoxifylline infusion proved unsuccessful. The skin biopsy and direct immunofluorescence revealed features were consistent with NS with overlap features of leukocytoclastic vasculitis, hitherto not reported. The literature of this preventable and iatrogenic disorder is reviewed, and plausible etiology is discussed.
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Affiliation(s)
- Bhaskara P. Shelley
- Department of Neurology, Yenepoya Medical College, Mangalore, Yenepoya (Deemed to be) University, Karnataka, India
| | - Prasanth Prasad
- Department of Medicine, Yenepoya Medical College, Mangalore, Yenepoya (Deemed to be) University, Karnataka, India
| | - Malla M. Manjunath
- Department of Dermatology, Yenepoya Medical College, Mangalore, Yenepoya (Deemed to be) University, Karnataka, India
| | - Shrijeet Chakraborti
- Department of Pathology, Kasturba Medical College (Manipal University), Mangalore, Karnataka, India
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Enshaei A, Afshar A. Compartment Syndrome of the Calf Due to Nicolau Syndrome. Arch Bone Jt Surg 2016; 4:87-89. [PMID: 26894227 PMCID: PMC4733244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 05/07/2015] [Indexed: 06/05/2023]
Abstract
We report a case of Nicolau syndrome in a 15 months old girl following an intramuscular injection of penicillin 6.3.3 in her left buttock. This case is unique because she developed compartment syndrome in her left calf far from her injection site. Her toe's tips gangrened in the course of her ailment. We hypothesized that the compartment syndrome might be produced by a probable intra-arterial injection that had produced embolic obstruction of the small and medium size arteries in her leg or a probable perineural or periarteial injection had produced secondary sympathetic stimulation, extensive vasospasm, compromised microcirculation and the development of compartment syndrome.
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Affiliation(s)
- Ali Enshaei
- The Department of Orthopedics, Urmia University of Medical Sciences, Urmia, Iran
| | - Ahmadreza Afshar
- The Department of Orthopedics, Urmia University of Medical Sciences, Urmia, Iran
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