J Korean Orthop Assoc.  2015 Aug;50(4):333-336. 10.4055/jkoa.2015.50.4.333.

Nicolau Syndrome Following Intramuscular Diclofenac Injection

• Ahn SJ
• Kang SW
• Kim BH
• Song MH
• Yoo SH
• Kim YJ
• Kim DH

• KMID: 2035871
• DOI: http://doi.org/10.4055/jkoa.2015.50.4.333

Abstract

Nicolau syndrome is a rare complication causing severe pain and tissue necrosis after intramuscular injection. In Korea, the Korea Dermatological Association has reported 12 cases, and some severe cases required surgical treatment. Most cases have been related to the administration of a variety of drugs, including nonsteroidal anti-inflammatory drugs, corticosteroids, and antibiotics. We present two patients who developed this complication, 1 case of typical Nicolau syndrome and 1 case of atypical Nicolau syndrome.

Keyword

intramuscular injection; nonsteroidal anti-inflammatory drugs (NSAIDs); Nicolau syndrome

MeSH Terms

Adrenal Cortex Hormones
Anti-Bacterial Agents
Diclofenac*
Humans
Injections, Intramuscular
Korea
Necrosis
Adrenal Cortex Hormones
Anti-Bacterial Agents
Diclofenac

Figure

• 

  Figure 1 (A) Large necrotic skin patch measuring 10×10 cm over the left buttock. (B) T2-weighted magnetic resonance imaging: diffuse high signal intensity in the left gluteal muscle.

• 

  Figure 2 (A) Diffuse livedoid pattern in the left buttock. (B) T2-weighted magnetic resonance imaging: pelvis showing swelling and abnormal signal in left gluteal muscles.

Reference

1. Nicolau S. Dermite Livedoide et Gangreneuse de la Fesse, Consecutive aux Injections Intramusculaires, dans la Syphilis. A Propos d'un Cas d'Embolie Arterielle Bismuthique. Ann Mal Vener. 1925; 20:321–339.

2. Go JW, Kim SH, Ro BI, Oh HE, Cho HK. Embolia cutis medicamentosa following intramuscular injection of diclofenac. Korean J Dermatol. 2010; 48:786–789.

3. Lie C, Leung F, Chow SP. Nicolau syndrome following intramuscular diclofenac administration: a case report. J Orthop Surg (Hong Kong). 2006; 14:104–107.

4. De Sousa R, Dang A, Rataboli PV. Nicolau syndrome following intramuscular benzathine penicillin. J Postgrad Med. 2008; 54:332–334.

5. Faucher L, Marcoux D. What syndrome is this? Nicolau syndrome. Pediatr Dermatol. 1995; 12:187–190.

6. McGee AM, Davison PM. Skin necrosis following injection of non-steroidal anti-inflammatory drug. Br J Anaesth. 2002; 88:139–140.

7. Duque FLV, Chagas CAA. Intramuscular accident with drug injection in the deltoid muscle: local and distant lesions, review of 32 cases. J Vasc Bras. 2009; 8:238.

8. Cockshott WP, Thompson GT, Howlett LJ, Seeley ET. Intramuscular or intralipomatous injections? N Engl J Med. 1982; 5. 307:356–358.

9. Kim DH, Oh GN, Kim JY, et al. Successful treatment of nicolau syndrome with platelet rich plasma. Korean J Dermatol. 2013; 51:69–71.

10. Cherasse A, Kahn MF, Mistrih R, Maillard H, Strauss J, Tavernier C. Nicolau's syndrome after local glucocorticoid injection. Joint Bone Spine. 2003; 70:390–392.