Nicolau syndrome following intramuscular benzathine penicillin injection: a case report

Abstract

Nicolau syndrome (NS) is a rare injection site reaction, following intramuscular injection of drugs characterized by severe pain, skin discoloration and varying level of tissue necrosis. The case outcomes vary from severe pain, atrophic ulcers to sepsis and limb amputation. We describe a case of the five-year-old girl with diagnosis of NS after intramuscular benzathine penicillin injection. The case was complicated with above the knee amputation of lower limb. This case report intends to remind clinicians that such rare cases should always be thought of in all patients receiving whatsoever drug via intramuscular injections.

Nicolau syndrome after intramuscular injection of methocarbamol: A rare case report

“…The necrotic changes can progress rapidly, leading to the formation of deep ulcers, cellulitis, and even abscesses [10] . Prompt recognition and intervention are crucial to prevent further tissue damage and complications [4] .…”

“…The exact pathogenesis of Nicolau syndrome is not well understood, but it is believed to involve a combination of mechanical injury, chemical irritation, and vascular occlusion leading to tissue necrosis [3] . The injection technique, patient-specific factors, and substance injected are all thought to contribute to the development of this syndrome [4] .…”

“Needle micro-cores: can they pose an occlusive threat with non-particulate injections?”

“…[12][13][14] Although injectable products composed of hydrocolloid gels and particulate mixtures-such as dermal fillers and drug suspensions-carry the greatest risk of vascular occlusion, recent reports have described injuries occurring with nonparticulate solutions such as lidocaine, botulinum, and other injectable medications. [15][16][17][18][19][20][21][22][23] Whereas the occlusive nature of filler-induced injuries has been well-established in the literature, the underlying mechanism of injury with nonparticulate injections has not been fully elucidated. 24 Current hypotheses include prolonged traumatic arteriospasm and intraluminal thrombus formation followed by distal embolization.…”

Can betamethasone prevent Nicolau syndrome when coadministered with penicillin? A case report

“…There are several case reports of NS following the administration of benzathine penicillin. For example, an intramuscular injection of this drug in a 4‐year‐old child 8 h after the injection eventually resulted in amputation of the lower limb 15 . Recently, two case reports of NS following intramuscular injection of benzathine penicillin have been reported as an ischemic necrotic event that occurs iatrogenically for the skin and deeper tissues 16 .…”