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Soares DJ, McCarthy AD. The Impact of Gel Parameters on the Dispersal and Fragmentation of Hyaluronic Acid Gel Fillers within an Artificial Model of Arterial Embolism. Gels 2024; 10:530. [PMID: 39195059 DOI: 10.3390/gels10080530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2024] [Revised: 08/07/2024] [Accepted: 08/09/2024] [Indexed: 08/29/2024] Open
Abstract
Accidental arterial embolization of hyaluronic acid (HA) fillers can lead to severe complications, including skin ischemia, blindness, and stroke. Currently, the intra-arterial dispersal and fragmentation behavior of HA gels is unknown but critical to our understanding of the pathomechanism of these injuries. This work introduces the Pulsatile Unit for the Laboratory Simulation of Arterio-embolic Restrictions (PULSAR) and evaluates the intravascular behavior of different HA gels. The fragmentation and dispersal behaviors of four HA gels with distinct rheological properties were evaluated via high-resolution videography and ImageJ particle size and morphology analysis. The gels' elastic modulus (G'), loss modulus (G″), tan(δ), and HA concentration were subsequently correlated with their intra-arterial behaviors. This study effectively confirms the extensive fragmentation of HA gels upon arterial inoculation, with particle sizes ranging from <50 µm to >1 mm. Gel particle size and morphology correlated most significantly with tan(δ). Conversely, arterial flow rates did not significantly influence gel fragmentation behavior, though the probability of proximal, macrovascular obstruction was affected. Overall, this study validates the PULSAR model for simulation of arterial dynamics and the testing of intravascular filler kinematics. The findings demonstrate the ability of gels to microfragment and disseminate distally, as well as induce partial proximal occlusion depending on gel rheology and arterial flow parameters.
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Affiliation(s)
- Danny J Soares
- College of Medicine, University of Central Florida, Orlando, FL 32827, USA
- American Foundation for Aesthetic Medicine, Fruitland Park, FL 34731, USA
| | - Alec D McCarthy
- American Foundation for Aesthetic Medicine, Fruitland Park, FL 34731, USA
- Merz Aesthetics Inc., Raleigh, NC 27615, USA
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Amorim RO, Silva ALCCD, Seque CA, Porro AM. Extensive Nicolau syndrome following intramuscular diclofenac sodium injection. An Bras Dermatol 2024; 99:123-125. [PMID: 37743206 DOI: 10.1016/j.abd.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 06/02/2022] [Accepted: 06/03/2022] [Indexed: 09/26/2023] Open
Affiliation(s)
| | | | - Camila Arai Seque
- Department of Dermatology, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Adriana Maria Porro
- Department of Dermatology, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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Zargarbashi R, Panjavi B, Keshavarz-Fathi M. Extensive Deep Tissue Involvement in Nicolau Syndrome and Below-Knee Amputation: A Case Report and Literature Review. THE INTERNATIONAL JOURNAL OF LOWER EXTREMITY WOUNDS 2023; 22:113-116. [PMID: 32806967 DOI: 10.1177/1534734620948768] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Nicolau syndrome (NS) is a rare cutaneous drug reaction in response to injections administered via any route. Based on the available studies in the medical literature, NS presents as skin and subcutaneous fat necrosis, and typically, it does not cause severe complications such as acute limb ischemia or death. In this study, we report the case of a 6-year-old boy who received an intramuscular injection of benzathine penicillin G for the treatment of bacterial pharyngitis, and subsequently developed a severe case of NS, which eventually led to below-knee amputation of the right lower limb. Although a few approaches have been suggested for the management of NS, they might not be effective under certain circumstances. Early detection, close monitoring, and consistent interventions, such as surgical fasciotomy and debridement procedures, might be necessary in severe cases of NS.
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Affiliation(s)
- Ramin Zargarbashi
- Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Behnam Panjavi
- Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahsa Keshavarz-Fathi
- Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.,Cancer Immunology Project, Universal Scientific Education and Research Network, Tehran, Iran
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Andraska EA, Phillips AR, Reitz KM, Asaadi S, Ho J, McDonald MM, Madigan M, Liang N, Eslami M, Sridharan N. Young patients without prior vascular disease are at increased risk of limb loss and reintervention after acute limb ischemia. J Vasc Surg 2022; 76:1354-1363.e1. [PMID: 35709858 PMCID: PMC9890507 DOI: 10.1016/j.jvs.2022.04.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/16/2022] [Accepted: 04/24/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND The objective of the present study was to categorize the presentation and treatment of acute limb ischemia (ALI) in young patients and compare the adverse outcomes after revascularization compared with that of older patients. METHODS All the patients who had presented to a multi-institution healthcare system with ALI from 2016 to 2020 were identified. The presenting features, operative details, and outcomes were included in the present analysis. Patients with existing peripheral arterial disease (acute on chronic) were analyzed separately from those without (de novo thrombosis or embolus). Within these groups, younger patients (age, ≤50 years) were compared with older patients (age, >50 years). The 3-month major adverse limb event-free survival was the primary outcome. RESULTS A total of 232 patients (age, 60 ± 16 years; 44% female sex, 87% white race) were included in the analysis. Of the 232 patients, 119 were in the acute on chronic cohort and 113 were in the de novo thrombosis/embolism cohort. Age did not affect the overall outcomes (P = .45) or the outcomes for the acute on chronic group (P = .17). However, in the de novo thrombosis/embolism cohort, patients aged ≤50 years had worse major adverse limb event-free survival compared with patients aged >50 years (hazard ratio, 2.47; 95% confidence interval, 1.08-5.68; P = .03) after adjustment for Rutherford class, interval from presentation to the operating room, and smoking status. In the de novo thrombosis/embolism group, the operative approach was similar across the age groups (endovascular, 12% vs 14%; open, 48% vs 41%; hybrid, 41% vs 45%; P = .78). In the younger patients, embolism was more likely from a proximal arterial source (71%). In contrast, in the older patients, the source of embolism was more often a cardiac source (86%). The rates of hypercoagulable disease were equal across the age groups (10% vs 10%; P = .95). The In-hospital mortality was 3% overall (acute on chronic, 5%; de novo, 3%). CONCLUSIONS Despite advances in interventional options, for patients with ALI due to de novo thrombosis or embolus, younger age was associated with worse short-term limb-related outcomes.
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Affiliation(s)
- Elizabeth A Andraska
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Amanda R Phillips
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Katherine M Reitz
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Sina Asaadi
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jonathan Ho
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Michael Madigan
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Nathan Liang
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Mohammad Eslami
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Natalie Sridharan
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
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Murdock JL, Duco MR, Sharma SC, Reeves DJ. Embolia Cutis Medicamentosa (Nicolau Syndrome) Secondary to Intramuscular Fulvestrant Injection: A Case Report. J Pharm Pract 2021; 35:1034-1038. [PMID: 33910404 DOI: 10.1177/08971900211012263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE A case of embolia cutis medicamentosa (Nicolau syndrome) in a patient receiving monthly intramuscular fulvestrant injections is presented. SUMMARY An 85-year-old woman receiving monthly fulvestrant injections in the outpatient setting developed a necrotic lesion at the fulvestrant injection site on her right buttock. Her medical history is notable for metastatic breast cancer with bone metastases. Prior to developing the necrotic lesion, the patient was receiving monthly fulvestrant injections for 6 years. Other potential causes such as infection and pressure necrosis were ruled out clinically. After 185 days of wound care involving multiple surgical debridements, topical therapy, and frequent follow-up appointments, the patient's wound resolved with 100% epithelialization. Nicolau syndrome has been reported with other non-vesicant, injectable medications such as antibiotics and corticosteroids; however, it has not been previously reported with fulvestrant. CONCLUSION Nicolau syndrome developed in the right buttock of a patient with metastatic breast cancer following an intramuscular fulvestrant injection. Healthcare practitioners need to be cognizant of this adverse effect with intramuscular injections in order to recognize and refer patients for wound care evaluation early in the evolution of this syndrome. Proper injection technique is recommended to reduce the risk of this idiopathic adverse effect.
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Affiliation(s)
- Joshua L Murdock
- College of Pharmacy and Health Science, Butler University, Indianapolis, IN, USA
| | - Marissa R Duco
- College of Pharmacy and Health Science, Butler University, Indianapolis, IN, USA
| | - Subhash C Sharma
- Franciscan Physician Network Oncology and Hematology Specialists of Indianapolis, Franciscan Health Indianapolis, IN, USA
| | - David J Reeves
- College of Pharmacy and Health Science, Butler University, Indianapolis, IN, USA.,Franciscan Physician Network Oncology and Hematology Specialists of Indianapolis, Franciscan Health Indianapolis, IN, USA
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Santiago MB, Paz A. Acute Peripheral and/or Cutaneous Ischemic Syndrome: What Rheumatologists Should Know. J Clin Rheumatol 2021; 27:73-79. [PMID: 33315786 DOI: 10.1097/rhu.0000000000001609] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT In daily practice, the frequent appearance of limb and/or skin necrosis, which we term "acute peripheral and/or cutaneous ischemic syndrome" (APCIS), can be a manifestation of numerous underlying diseases, or it can sometimes be a clinical phenomenon whose etiology is undefined even after a wide investigation. The mechanisms for the development of APCIS include vessel wall abnormalities (atherosclerosis, vasculitis, and calciphylaxis), embolic processes (infectious endocarditis, atrial myxoma, and cholesterol emboli), local thrombotic injuries (genetic or acquired thrombophilias and heparin- and warfarin-induced ischemia), dysproteinemias (cryoglobulinemia and cryofibrinogenemia), or venous limb gangrene. Here, we report 5 illustrative cases of APCIS with different pathogenetic mechanisms, thereby highlighting some clinical conditions that cause APCIS that may be of special interest for rheumatologists, such as antiphospholipid syndrome, primary and secondary vasculitis, and cryoproteinemias. Furthermore, we describe a large spectrum of other causes of APCIS beyond the scope of rheumatology. Because there are no validated guidelines for APCIS, we tentatively propose an initial diagnostic workup and a therapeutic approach based on full-dose anticoagulation and immunosuppressive therapy.
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Affiliation(s)
| | - Adriane Paz
- From the Hospital Universitário Professor Edgard Santos
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7
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[Cutaneous disorders caused by physical damage mimicking rheumatic diseases]. Z Rheumatol 2020; 79:1025-1032. [PMID: 32410116 DOI: 10.1007/s00393-020-00814-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The skin is the primary interface between the body and the environment. It is exposed to a variety of external physical factors to which it must respond in a dynamic manner. In the following review such cutaneous reactions to physical damage are discussed under the aspects of rheumatological differential diagnoses. In particular, circumscribed hyperpigmentation and hyperkeratosis, reactive patterns to cold, with or without humidity, and lightning are presented. Most of these disorders do not need extensive laboratory investigations or imaging techniques. Knowledge of such cutaneous disease symptoms due to physical damage prevents overdiagnostics and possible overtreatment.
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Lardelli PF, Jermini LMM, Milani GP, Peeters GGAM, Ramelli GP, Zgraggen L, Terrani I, Bianchetti MG, Vanoni F, Faré PB, Lava SAG. Nicolau syndrome caused by non-steroidal anti-inflammatory drugs: Systematic literature review. Int J Clin Pract 2020; 74:e13567. [PMID: 32479658 DOI: 10.1111/ijcp.13567] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 04/05/2020] [Accepted: 05/26/2020] [Indexed: 12/16/2022] Open
Abstract
AIM Intramuscular or, more rarely, local drug injection is occasionally followed by immediate local pain, livedoid skin lesions and, some days later, the development of ischemic lesions. This very uncommon but potentially severe reaction, termed Nicolau syndrome, is traditionally associated with bismuth and β-lactam antimicrobials. The aim of this report was to review the literature associating Nicolau syndrome with the administration of non-steroidal anti-inflammatory drugs. METHODS The National Library, Excerpta Medica, Web of Science and Cochrane library databases were used. RESULTS Sixty-two cases (40 females and 22 males aged from 13 to 81, median 57 years) of Nicolau syndrome were published after 1992. Fifty-three cases occurred after diclofenac. The remaining nine cases were associated with ketoprofen (N = 2), ketorolac (N = 2), phenylbutazone (N = 2), etofenamate (N = 1), ibuprofen (N = 1) and piroxicam (N = 1). CONCLUSION Although Nicolau syndrome is extremely uncommon, physicians must be aware of this complication after intramuscular administration of non-steroidal anti-inflammatory drugs and should avoid unnecessary injections.
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Affiliation(s)
- Pietro F Lardelli
- Pediatric Institute of Southern Switzerland, Ospedale San Giovanni, Bellinzona, Switzerland
| | | | - Gregorio P Milani
- Pediatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Gabriella G A M Peeters
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano, Milan, Italy
| | - Gian P Ramelli
- Pediatric Institute of Southern Switzerland, Ospedale San Giovanni, Bellinzona, Switzerland
| | - Lorenzo Zgraggen
- Pediatric Institute of Southern Switzerland, Ospedale San Giovanni, Bellinzona, Switzerland
| | - Isabella Terrani
- Department of Dermatology, Ente Ospedaliero Cantonale, Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Mario G Bianchetti
- Pediatric Institute of Southern Switzerland, Ospedale San Giovanni, Bellinzona, Switzerland
- Università della Svizzera Italiana, Lugano, Switzerland
| | - Federica Vanoni
- Pediatric Institute of Southern Switzerland, Ospedale San Giovanni, Bellinzona, Switzerland
| | - Pietro B Faré
- Department of Internal Medicine, Ente Ospedaliero Cantonale, Locarno, Switzerland
| | - Sebastiano A G Lava
- Pediatric Cardiology Unit, Department of Pediatrics, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Raherinantenaina F, Rajaoharimalala T, Ranaivo I, Ralandison S, Rakoto Ratsimba H, Rajaonanahary TA. Compartment syndrome and acute lower limb ischemia with paralysis complicating intramuscular benzathine penicillin injection. FORMOSAN JOURNAL OF SURGERY 2020. [DOI: 10.4103/fjs.fjs_50_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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