Nicolau Syndrome: An Unforeseen Yet Evadable Consequence of Intramuscular Injection

Abstract

An intramuscular (IM) injection is one of the common routes for administering drugs, commonly analgesics and vaccines. Nicolau syndrome refers to the rapid-onset painful, extensive cutaneous discoloration progressing to necrosis and ulceration, reported after IM injections. This case report highlights a rare but avoidable complication of such injections. An elderly man presented with extensive cutaneous necrosis and discoloration over the buttocks extending to the thigh, within few days after receiving a single shot of IM injection of diclofenac. Management involved wound care, biopsy, and cultures with supportive antibiotics to control superadded infection. After multiple sittings of extensive surgical debridement, the wound showed signs of healing and was ultimately amicable for skin grafting in a month.Health care workers need sensitization toward such a complication that can occur out of a routine procedure like an IM injection. They should follow standard IM injections techniques and take precautions to avoid this mishap, which adds to the patient's morbidity.

Nikolau Syndrome: Necrotic Activity of Drugs and Ways to Prevent Post-Injection Abscesses (In memory of Professor László A Gömze)

“…Local post-injection infl ammation, severe local pain syndrome, erythematous skin damage, necrosis and abscess remain the most striking, demonstrative and, at the same time, insuffi ciently explained [20][21][22]. Th is complex of local post-injection complications was fi rst described about 100 years ago [23] and is called Nicolau syndrome [24][25][26].…”

Thermal imaging of local skin temperature as part of quality and safety assessment of injectable drugs

“…Among complex local post-injection complications, reversible and irreversible local inflammation, severe local pain syndrome, necrosis, and abscess are the most unpredictable and unexplained [ [26] , [27] , [28] ]. This specific complication was described approximately 100 years ago [ 29 ], and is now called Nicolau syndrome [ [30] , [31] , [32] , [33] , [34] , [35] ].…”

“…However, these notions do not explain cases of instant local pain, inflammation, necrosis, or abscesses at the drug injection site [ 45 , 46 ]. Additionally, post-injection complications are often aseptic [ 7 , 24 , 27 , 28 , 43 ].…”

Inflammation, Infiltration, Necrosis, Abscess and Nicolau Syndrome after Injection of Nonsteroidal Anti-inflammatory Drugs: What is the Reason?

“…Since then, several reports have appeared in the literature about this disease occurring after intramuscular, intra-articular, intravenous, and subcutaneous injections associated with various drugs, such as NSAIDs, (for example, diclofenac sodium), vitamin K, antibiotics (such as penicillin), antihistamines, corticosteroids (for example triamcinolone acetonide), local anesthetics, vaccines, antiepileptics, polidocanol, and pegylated alphainterferon. The pathogenesis of Nicolau syndrome is unknown [9][10][11][12]. However, since 2002, reports have begun to appear that the cause of such post-injection complications may not be the drug, which is the main ingredient, but the chemical and physicochemical properties of the excipients of the injectable preparation in which the medicine is diluted.…”