Nicolau syndrome after benzathine penicillin treated with hyperbaric oxygen therapy

Post-injection embolia cutis medicamentosa – Nicolau Syndrome: case report and literature review

“…Nicolau syndrome has lower incidence than all of these complications. [1][2][3]10,11 Children less than 12 years old are more susceptible to developing NS after administration of antibiotics. 12,13 Nicolau syndrome occurs with greater frequency in obese patients and women, since they have larger deposits of fat tissues in the gluteal region, which prevents needles from reaching muscle tissues.…”

“…However, immunologic response mechanisms have been ruled out because recurrence of NS with the same pharmacological agent has not been described. 3,6,8,11,12,17,18 Nicolau observed the presence of residues of bismuth salts in histological examination of the lumen of small vessels, which may have caused an embolic process. Furthermore, in 1967, occlusive substances were found in arteries of the forearm of a patient who suffered from NS after penicillin injection and this not only confirms the embolic pathophysiological mechanism, but also confirms that NS can cause lesions outside of the original area.…”

“…Nicolau syndrome can be fatal in children. 3,7,9,13,22 Furthermore, the syndrome can cause neurological complications, such as paraplegia, hypoesthesia, and stereognosis. In 2010, a case of NS was described that progressed to irreversible lesion of a lower limb and vesical sphincter dysfunction, caused by a reduction of blood flow in the inferior gluteal artery, which led to compromised irrigation of the sciatic and pudendal nerves.…”

“…Nicolau syndrome can also be similar to an abscess. 3,4,14,17,23,24 There is no standard treatment established for NS, since it has a low incidence. In most cases, methods such as surgical debridement and local repair through grafts or myocutaneous flap combined with anticoagulants, pentoxifylline, hyperbaric chamber, steroids, intravenous alprostadil, corticosteroids and analgesics are employed until the lesion is completely healed.…”

“…1 Nicolau syndrome or embolia cutis medicamentosa is a rare complication that can occur after intramuscular, intra-articular or subcutaneous injections. 2,3 The incidence of complications of intramuscular injections varies between 0.4% and 19.3% and the most common forms are sciatic nerve injury, hematoma, and bleeding. 1 Nicolau syndrome presents with pain at the site of injection immediately after drug administration, followed by hyperemia, skin discoloration, abscess formation, and ischemic necrosis and severe cases can even lead to death.…”