Nicolau Syndrome Following Metamizole Injection: A Case Report

Introduction::Nicolau syndrome is a rare complication following intramuscular injections of various drugs. It is characterized by severe pain, skin and sometime...     

Embolia cutis medicamentosa following subcutaneous injection of glatiramer acetate

Embolia cutis medicamentosa (ECM) is a rare side effect observed primarily after intramuscular injections. It is associated with localized, sometimes extensive necrosis of the skin. Reflex vasospasm induced by the injection trauma may be etiologically involved. It is a potentially serious reaction which is little influenced by which drug is injected. A patient developed typical ECM after subcutaneous selfinjection of glatiramer acetate for multiple sclerosis. This case is remarkable since 1) ECM developed after subcutaneous and not after intramuscular injection, 2) the injection was given by the patient himself, and 3) glatiramer acetate can induce skin necrosis as a side effect. ECM can be easily differentiated from the latter by its typical clinical features.     

Intramuscular diclofenac is a cause of Nicolau syndrome in obese women: An observational study of consecutive ten patients

Nicolau syndrome is a skin and underlying tissue necrosis resulting from vascular occlusion after various injections of certain drugs. Intramuscular injections are the most common cause but it may occur after other types of parenteral interventions. There are many medications reported as causative factors inducing Nicolau syndrome including penicillin, nonsteroidal anti‐inflammatory drugs, corticosteroids, local anesthetics, and several others. We present an observational study of diclofenac induced Nicolau syndrome.     

Nicolau syndrome aggravated by cold application after i.m. diclofenac

Nicolau syndrome is a rare but well-recognized cutaneous adverse drug reaction at the site of i.m. injection of certain drugs. Clinically, it is characterized by severe pain immediately after the injection followed by an erythematous reticular patch that may result in a necrotic ulcer and scarring at the injection site. We describe a 60-year-old woman with a painful, violaceous, crusted plaque after i.m. diclofenac administration to her right buttock. She had applied an ice pack to this area immediately after the injection to relieve the pain without any benefit. A clinical diagnosis of Nicolau syndrome due to diclofenac injection was made, and reconstructive surgery of the wound was performed. Although diclofenac is a widely used non-steroidal anti-inflammatory drug, Nicolau syndrome following i.m. diclofenac injection has rarely been reported in the published work. Application of a cold compress was considered an aggravating factor in our patient.     

Three cases of embolia cutis medicamentosa (Nicolau’s syndrome)

Embolia cutis medicamentosa, also known as Nicolau’s syndrome, is a rare complication due to i.m. injections. Its real incidence is actually underestimated. Many drugs have been associated with it, but at the time only a few studies showed a related pathogenetic mechanism. Symptoms consist of immediate local pain, edema and cutaneous, subcutaneous and even muscular necrosis occurring in the first 48 h. The type of treatment depends mostly on time of diagnosis. A medical resolution can be achieved through heparin and cortisone injections within the first 48 h. Surgical debridement has to be considered as the main treatment in case of late diagnosis. We present three cases of Nicolau’s syndrome presenting to us in a short period of time that we treated with surgical debridement.     

Five cases of livedo-like dermatitis (Nicolau's syndrome) due to bismuth salts and various other non-steroidal anti-inflammatory drugs

The authors report five cases of Nicolau's syndrome observed over a period of about 25 years. The disease had occurred after intramuscular injections of different drugs (bismuth, diclofenac and ibuprofen). In all the described cases the clinical aspect was characterized by a livedoid pattern followed by a slow necrotizing evolution with scar formation; in some cases surgical debridement and plastic reconstructive surgery were performed. In the past Nicolau's syndrome was described after intramuscular injections of bismuth salts for the treatment of syphilis; now, although still rare, it is described after injections of various aqueous drug solutions. The pathogenesis of Nicolau's dermatitis appears to be more complex than the previous hypothesized embolism caused by oleous drugs.     

Nicolau syndrome and localized panniculitis: a report of dual diagnoses with an emphasis on morphea profunda‐like changes following injection with glatiramer acetate

Glatiramer acetate, given as a 40 mg subcutaneous injection thrice weekly, was recently approved by the FDA based on data suggesting better compliance and a more favorable side effect profile compared to lower dose, daily dosing. The most commonly reported adverse events are transient injection site reactions involving redness and pain at the site; however, more pronounced panniculitis and lipoatrophy have also been reported. Here, we present the case of a 51‐year‐old female treated with higher dose glatiramer acetate who presented with a cutaneous injection site reaction consistent with Nicolau syndrome. The excised specimen revealed typical glatiramer acetate‐associated panniculitis, alongside subcutaneous sclerosis. This case shows the spectrum of cutaneous complications possible with glatiramer acetate injections, the finding of sclerosis being relatively infrequently reported. Given the relatively short duration of trials leading to FDA approval of thrice weekly dosing of glatiramer acetate, clinicians should perform careful clinical and histopathological evaluation and reporting of patients who experience injection site reactions.     

Nicolau syndrome: A literature review

Nicolau syndrome(NS) is a rare cutaneous adverse reaction after intra-muscular or intra-articular injection. Clinical features of NS are presented by three typical phases(initial, acute and necrotic phases). The cause of NS is acute vasospasm, inflammation of arteries and thromboembolic occlusion of arteriole related various drugs. Many results of laboratory test, imaging studiesand histopathology are reported and are associated with disease status. Three phase treatment is recommended for the patients with NS. Initially pain control and rule out differential diagnosis and in acute phase steroid therapy, heparin and pentoxifylline are useful. In necrotic phase, surgical treatment is needed depending on size of the affected site. NS is not well understood so far, however three phase treatment could lead to good result on basis of literature review.     

Nicolau Syndrome in Patient Following Diclofenac Administration: A Case Report

Nicolau syndrome is a rare adverse reaction to a variety of intra-muscular drug preparations. The typical presentation is pain around the injection site soon after injection, followed by erythema, livedoid patch, hemorrhagic patch, and finally, necrosis of skin, subcutaneous fat, and muscle tissue. The phenomenon has been related to the administration of a variety of drugs, including non-steroidal anti-inflammatory drugs, corticosteroids, and penicillin. We report a case with typical features associated with diclofenac injection for pain control in a patient who had undergone bilateral total knee arthroplasty.     

Bart syndrome associated with skeletal deformities: An uncommon case report

Bart syndrome is a rare genetic disorder characterized by aplasia cutis congenita, epidermolysis bullosa (EB), and nail abnormalities. We reported an unusual case of Bart syndrome associated with skeletal abnormalities and bilateral clubfoot.     

Late development of Nicolau syndrome: case report

Nicolau syndrome also known as Embolia cutis medicamentosa and Livedoid dermatitis is a rare complication characterized by tissue necrosis that occurs after injection of medicines. We describe a case of late development of Nicolau syndrome following intra-articular infiltration with corticosteroid.     

皮损内注射复方倍他米松治疗Wells综合征一例

报告1例61岁女性患者,右前臂结节、斑块伴瘙痒1年。皮损组织病理示:真皮中下层见大量淋巴细胞及嗜酸粒细胞浸润,部分胶原束内可见嗜酸粒细胞脱颗粒形成火焰现象。诊断:Wells综合征(嗜酸性蜂窝织炎)。皮损内注射糖皮质激素治疗3个月后皮损消退,随访6个月未见复发。     

Facial intramuscular lipoma occurrence following topical cosmetic injection with a mixture of basic fibroblast growth factor: A report of two cases

Growth factors and cytokines control cell growth, proliferation and differentiation via a network of inter- and intracellular signalling pathways, and are involved in skin self-renewing and wound healing. In recent years, topical and injectable growth factors and cytokines have emerged as an intriguing therapeutic modality that can be harnessed for aesthetic purposes. However, very little data are available on their long-term safety and tolerability. In this report, we describe two cases of patients, who developed intramuscular lipoma of the chin following topical injection with a mixture of basic fibroblast growth factor as the main ingredients for chin augmentation. Biopsies in the two cases were performed at our department, and revealed intramuscular lipoma. Our report indicates that the topical injection of growth factors can lead to tumorigenesis, so health care providers need to be aware of its potential consequences.     

Anetoderma arising in Reed syndrome: a case report and review of the literature

Anetoderma is a cutaneous disorder characterized by loss of dermal elastic tissue resulting in papules from herniation of subcutaneous tissue or circumscribed areas of atrophic, wrinkled skin. Familial leiomyomatosis cutis et uteri (Reed syndrome) is an autosomal dominant disorder characterized by cutaneous and uterine leiomyomas. We report a 23‐year‐old male with Reed syndrome who presented with asymptomatic pearly white, atrophic, flaccid papules on the upper back and shoulder that depressed when palpated. Pathologic examination showed an unremarkable epidermis and central loss of dermal elastin, bordered by clumped elastin, as revealed with an elastin stain. The correlation of clinical and pathologic findings indicated a diagnosis of anetoderma arising in a patient with Reed syndrome.     

Nicolau syndrome due to hyaluronic acid injections

Six cases of vascular compromise after hyaluronic injection are reported. Clinical symptoms realized a Nicolau syndrome, which is characterized by immediate pain, livedoid pattern and a few days later by the appearance of scabs and skin necrosis. This type of complication is rare, but may be dramatic and injectors must be aware of that. A thorough knowledge of facial anatomy is mandatory to avoid the risky facial areas. The use of a flexible cannula instead of a sharp needle has much less risk of hurting vessels and must be preferred. The support of the patient is discussed and a treatment protocol is proposed.     

胰高糖素瘤综合症1例

报告１ 例胰高糖素瘤综合征,女性,４３ 岁。临床特征： 反复、成批发生片状、表浅坏死性结痂性红斑, 伴体重减轻, 中度贫血, 糖耐量降低。影像学检查：胰尾４ｃｍ ×３ｃｍ 肿块, 术后病理证实为恶性胰岛细胞瘤。     

A case of intramuscular hemangioma of the back

Intramuscular hemangioma is an uncommon tumor that usually involves an extremity. They rarely occur after the age of 30. We report a case of an intramuscular hemangioma occurring on the back of a 39-year-old man. Histopathologically, the tumor consisted mainly of large vessels between the muscle fibers. Phleboliths were observed in some of the vessel walls.     

获得性皮肤松弛症

报告1例获得性皮肤松弛症。患者女,17岁。面颈、双腋窝及股部皮肤松弛2年。皮肤科检查:面颈、双腋窝及股部皮肤明显松弛,皱纹密集,皮沟加深,无弹性。左颈部皮损组织病理示:表皮厚度大致正常,网篮状角化,真皮浅层血管周围少量淋巴细胞浸润。弹性纤维染色示:真皮浅层弹性纤维数量明显减少、形态异常。诊断:获得性皮肤松弛症。