A case of Nicolau syndrome treated with hyperbaric oxygen

Abstract

<jats:title>Abstract</jats:title><jats:p>A 3-year-old boy with a Nicolau Syndrome (NS) on the left side of the body and the limbs after benzathine penicilline injection is reported. To the authors’ best knowledge, this is the first report of hyperbaric oxygen used in the late treatment of NS preventing the progress of the necrosis and therefore limiting the amputation level.</jats:p>

Does early hyperbaric oxygen therapy prevent extremity necrosis in Nicolau syndrome?

“…We started our patient on heparin, pentoxifylline, amlodipine and HBO treatment within 24 h of the diagnosis. To the best of our knowledge, only two cases of HBO use have been described in the medical literature: one started early and one started late, in the course of the first week after the diagnosis 2,5 . In the latter case, due to necrosis having progressed considerably, HBO treatment only limited the amputation level, whereas the two patients we followed (our patient and that of Ocak et al .)…”

“…When there are clinical signs of NS, the therapeutic approach is generally symptomatic and can range from local treatment to surgical intervention, and in some cases, extremity amputation. Close observation is especially important in children (regardless of the substance used), as lesions can spread across the entire extremity, leading to compartment syndrome and acute renal failure 1–5,7 . Use of vasoactive agents (heparin, pentoxifylline) may be beneficial considering the vascular pathogenesis.…”

“…Use of vasoactive agents (heparin, pentoxifylline) may be beneficial considering the vascular pathogenesis. Antibiotic use is restricted to the cases with signs and symptoms of infection 2,5 . We started our patient on heparin, pentoxifylline, amlodipine and HBO treatment within 24 h of the diagnosis.…”

“…In certain cases, the necrosis can be extensive; it may be accompanied by rectal hemorrhage, neurologic complications, compartment syndrome, acute renal failure and transient or permanent ischemia of the ipsilateral limb that may even require amputation. Furthermore, NS can be fatal in children 5–7 . Treatment consists of medical (heparin, pentoxifylline) and surgical (excision, grafting, etc.)…”

Tissue loss with subcutaneous immunotherapy—Nicolau syndrome

“…Although there is no standard treatment, early recognition and treatment with vasoactive and antiinflammatory agents such as subcutaneous heparin, oral pentoxifylline, and corticosteroids, or even early use of hyperbaric techniques could reduce tissue loss. 7 Conservative treatment also includes pain control, antibiotics, and dressings with possible surgical methods if necrosis is extensive. Knowledge of this potential adverse event may have relevance in consideration for aspiration before subcutaneous injection, use of intramuscular versus subcutaneous injection of epinephrine, ice or tourniquets, and close observation and early treatment of lesions suggestive of Nicolau syndrome.…”