Nicolau Syndrome After Intramuscular Benzathine Penicillin Treatment

Abstract

Nicolau syndrome (livedoid dermatitis) is a very rare complication of intramuscular injections and manifests as excruciating pain immediately after injection. We describe a 3-year-old boy with diagnosis of Nicolau syndrome after intramuscular benzathine penicillin injection to the midanterior part of the left thigh. He was treated with hyberbaric oxygen and pentoxyphilline in addition to supportive treatment and recovered with no sequelae.

Nicolau syndrome as an avoidable complication

“…Use of vasoactive agents such as subcutaneous heparin and oral pentoxifylline has been recognized as beneficial. [8] Topical steroids may be worth trying. Surgical intervention is rarely required.…”

A case of Nicolau syndrome treated with hyperbaric oxygen

“…Enoxaparin, pentoxyphylline and HBO treatment were given to our patient. To the best of our knowledge, there is only one case report in literature where HBO was used early in the treatment of NS with complete healing [9]. Our patient appears to be the second case of NS that was treated with HBO, but in the late period (after 1 week of diagnosis and after necrosis had ensued).…”

Freestyle Perforator-Based Fasciocutaneous Flap Reconstruction in Nicolau Syndrome-Related Tissue Necrosis

“…Rapid administration of steroids, anticoagulants, and vasoactive agents has been emphasized for clinical improvement and regression of the livedoid lesions whereas it has been demonstrated that heparin and pentoxifylline are useless in preventing the development of necrosis [1,3,10,22]. Hyperbaric oxygen treatment may be beneficial at the early onset of disease [10]. If NS is regarded as an unintended intra-arterial injection injury and recognized at early stages, treatment guidelines preceded by Sen et al from the Mayo Clinic may be beneficial [23].…”

“…The actual physiopathology of the NS is yet unknown; it has been proposed that the direct arterial damage and vasoconstrictive effects of various drugs may induce inflammation and subsequently cause skin necrosis [2,3]. Agents, such as nonsteroidal anti-inflammatory drugs, steroids, vitamines, benzathine penicillin, hydroxyzine, vaccines i.e., are reported to be potential triggering factors of this clinical entity [2,[4][5][6][7][8][9][10][11][12][13]. There is no consensus on the treatment protocol of the disease.…”