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Tawanwongsri W, Vachiramon V. Skin necrosis after intradermal injection of lyophilized exosome: A case report and a review of the literature. J Cosmet Dermatol 2024; 23:1597-1603. [PMID: 38327119 DOI: 10.1111/jocd.16206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/03/2024] [Accepted: 01/22/2024] [Indexed: 02/09/2024]
Abstract
BACKGROUND Exosomes have gained attention for their potential in skin rejuvenation. Currently, most exosome products are available for topical administration, and the use of subdermal injection as a route of administration has not been approved. AIMS The purpose of this case report is to describe a case of skin necrosis that occurred following an intradermal injection of lyophilized exosomes. MATERIALS AND METHODS We hereby report a case of a middle-aged man who experienced adverse effects after receiving an intradermal injection of lyophilized exosomes. Multiple injections of an exosome product were administered to treat enlarged facial pores. Shortly after the injection, the patient felt pain and noticed several dark red bumps. Three days after injection, the lesions transformed into palpable, painful, non-blanchable purplish papules and nodules, accompanied by central, tiny crusted erosions. The residual product was injected into the upper arm using an intradermal method. Similar lesions also appeared, and a skin biopsy showed necrotic keratinocytes, leukocytoclastic vasculitis, and eccrine necrosis. RESULTS There are few reports available regarding complications, especially those related to intradermal exosomes. These complications include multiple foreign-body granulomatous reactions at the injection sites. In our case, oral prednisolone was administered for a duration of 7 days. After the treatment, the lesions exhibited notable improvement, eventually leaving post-inflammatory hyperpigmentation. CONCLUSION Utilizing exosomes through unapproved methods should be avoided due to the possibility of adverse reactions that could cause aesthetic issues.
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Affiliation(s)
- Weeratian Tawanwongsri
- Division of Dermatology, Department of Internal Medicine, School of Medicine, Walailak University, Nakhon Si Thammarat, Thailand
| | - Vasanop Vachiramon
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Verma V, Chandra AD, Mehta N, Verma KK. Nicolau syndrome postintramuscular diclofenac injection: preventable iatrogenic error or an unfortunate sequalae? Int J Dermatol 2024; 63:396-398. [PMID: 38318715 DOI: 10.1111/ijd.17050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 11/29/2023] [Accepted: 01/12/2024] [Indexed: 02/07/2024]
Affiliation(s)
| | | | - Nikhil Mehta
- All India Institute of Medical Sciences, New Delhi, Delhi
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Fekete GL, Iantovics LB, Fekete JE, Fekete L. Embolia cutis Medicamentosa (Nicolau syndrome): case series. Front Med (Lausanne) 2023; 10:1216781. [PMID: 38020151 PMCID: PMC10653301 DOI: 10.3389/fmed.2023.1216781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 09/18/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Embolia cutis medicamentosa or Nicolau syndrome is a rare drug reaction associated with the administration of various injectable medications. The pathogenesis of the disease is unknown, though intra and periarterial injection of the drug is a possible cause. The aim of this study was to describe and analyze the clinical characteristics of Nicolau syndrome in patients examined in daily dermatological practice. Methods We performed a retrospective chart review, between January 2011 and December 2020, in patients diagnosed with Nicolau syndrome, from the cases of a private dermatology medical office in Târgu Mureș, Romania. Results During the 10-year period, 7 patients were diagnosed with Nicolau syndrome. Of these, 4 (57%) patients were males and 3 (43%) were females, The male to female ratio was 1.33. The median age was 64 (interquartile range, IQR, 62-71), with the youngest patient being diagnosed at age 61 and the oldest at age 74. Regarding the drugs classes that caused Nicolau syndrome, these were intravenous antibiotics in 57%, and non-steroidal anti-inflammatory drugs in 43% of cases. Conclusion All patients healed in a period of 6 to 8 weeks. No complications occurred. In conclusion, Nicolau syndrome is a rare side effect of injectable drug administration.
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Affiliation(s)
- Gyula Laszlo Fekete
- Department of Dermatology, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, Targu Mures, Romania
- CMI Dermamed Private Medical Office, Targu Mures, Romania
| | - Laszlo Barna Iantovics
- Department of Electrical Engineering and Information Technology, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, Targu Mures, Romania
| | - Júlia Edit Fekete
- National Institute of Public Health, Regional Center for Public Health, Targu Mures, Romania
| | - Laszlo Fekete
- CMI Dermamed Private Medical Office, Targu Mures, Romania
- Doctoral School, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, Targu Mures, Romania
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Day B, Thompson D, Mba-Jonas A, Alimchandani M. Reports of Injection Site Necrosis After 23-Valent Pneumococcal Vaccine Use. JAMA Intern Med 2023; 183:1015-1016. [PMID: 37399033 PMCID: PMC10318545 DOI: 10.1001/jamainternmed.2023.2146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 04/12/2023] [Indexed: 07/04/2023]
Abstract
This case series uses postmarketing data to evaluate the incidence of injection site necrosis after 23-valent pneumococcal vaccine use in the global market.
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Affiliation(s)
- Brendan Day
- Office of Biostatistics and Pharmacovigilance, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Deborah Thompson
- Office of Biostatistics and Pharmacovigilance, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Adamma Mba-Jonas
- Office of Biostatistics and Pharmacovigilance, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Meghna Alimchandani
- Office of Biostatistics and Pharmacovigilance, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
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Das S, Shet V, Jogarajah T, Ibrahim A, Reyes M, Fernandez Co EM, Reddy B. Nicolau syndrome associated with fluphenazine depot: A case report. SAGE Open Med Case Rep 2023; 11:2050313X231180747. [PMID: 37440972 PMCID: PMC10333627 DOI: 10.1177/2050313x231180747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/22/2023] [Indexed: 07/15/2023] Open
Abstract
Nicolau syndrome is a rare condition characterized by severe pain at the site of injection, leading to ulceration and necrosis of the local tissues. Its presentation is usually acute. Nicolau syndrome is commonly seen in patients after intramuscular, intra-articular, or subcutaneous injections of non-steroidal anti-inflammatory drugs, antiepileptics, antipsychotics, antibiotics, antihistamines, and corticosteroids. Immediate diagnosis and management of this syndrome are of great importance. We herein report a rare presentation of Nicolau syndrome in a 36-year-old married male who suffered from paranoid schizophrenia for the past 3 years. The patient presented with dull pain, mild swelling, and necrotic ulceration over the injection site after receiving intramuscular fluphenazine. The patient underwent wound debridement and was given prophylactic antibiotics. Despite a wide range of therapeutic options for the management of Nicolau syndrome described in the literature, there exist limited guidelines for its management.
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Affiliation(s)
- Soumitra Das
- The Royal Melbourne Hospital,
Parkville, VIC, Australia
| | - Vallabh Shet
- Bangalore Medical College &
Research Institute, Bangalore, India
| | - Thusanth Jogarajah
- Faculty of Medicine, Richmond Gabriel
University, Belair, Saint Vincent and the Grenadines
| | - Abdulgafar Ibrahim
- Institute for Biomedical Sciences,
Georgia State University, Atlanta, GA, USA
| | - Marlon Reyes
- American University of Antigua College
of Medicine, St. John’s, Antigua and Barbuda
| | | | - Balaswamy Reddy
- Department of Psychiatry, National
Institute of Mental Health and Neurosciences, Bengaluru, India
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Anees A, Hassan Y, Motiwala ZY, Khan IR. Tissue Damage Caused by Diclofenac Intramuscular Injection: The Nicolau Syndrome. IBNOSINA JOURNAL OF MEDICINE AND BIOMEDICAL SCIENCES 2023. [DOI: 10.1055/s-0043-1761214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Abstract
Introduction Nicolau syndrome is an extremely rare complication following intramuscular administration of drugs leading to tissue damage and necrosis.
Case Report In this case, the patient received the injection from an untrained quack surgeon (Jarrah) due to an improper intramuscular injection technique. A 45-year-old female complained of pain and blackish discoloration of the skin over the left buttock after receiving an intramuscular diclofenac injection.4 The patient was managed by administering intravenous antibiotics and analgesics, followed by surgical debridement. Flap reconstruction was done after granulation tissue formation.
Conclusion Healthcare should be sought from appropriately trained and licensed professionals. Patients should be well educated on this. Pain, erythema, and discoloration should be recognized as red flags of the Nicolau syndrome so that it can be addressed promptly to avoid complications.
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Affiliation(s)
- Afzal Anees
- Department of Surgery, Jawaharlal Nehru Medical College, AMU, Aligarh, India
| | - Yaqoob Hassan
- Department of Surgery, Jawaharlal Nehru Medical College, AMU, Aligarh, India
| | | | - Isna Rafat Khan
- Department of Surgery, Jawaharlal Nehru Medical College, AMU, Aligarh, India
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Kang M, Yang A, Hannaford P, Connor D, Parsi K. Skin necrosis following sclerotherapy. Part 1: Differential diagnosis based on classification of pathogenic mechanisms. Phlebology 2022; 37:409-424. [PMID: 35503729 DOI: 10.1177/02683555221088101] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
Background: Tissue necrosis is a significant but uncommon complication of sclerotherapy. The pathogenic mechanisms of this often-debilitating complication have been poorly described in the literature.Purpose: To elucidate the pathological mechanisms, we propose a morphological approach to classify sclerotherapy-induced skin necrosis into two categories of round and stellate (star-like) necrosis.Research Design: Comprehensive literature review was conducted.Results: Round necrosis is typically caused by extravasation of sclerosants. It typically presents as an ulcer with smooth and non-geographic borders. Historically, extravasation has been cited as the main cause of sclerotherapy-related necrosis. While this may be the case with osmotic or irritant sclerosants, it is far less likely with the use of detergent agents particularly in the foam format.The more commonly encountered pattern of stellate necrosis is an ischaemic ulcer secondary to arterial/arteriolar occlusion. In contrast to round necrosis, stellate necrosis follows an intra-vascular injection of sclerosants such as an inadvertent intra-arterial injection. But more frequently, stellate necrosis may follow a perfectly executed intra-venous or intra-telangiectatic delivery of sclerosants. Several pathogenic pathways can be considered. The physiologic response of veno-arteriolar reflex vasospasm (VAR-VAS) is possibly the most frequent pathway. It follows a high-pressure injection of the sclerosant in a target vein resulting in a rapid rise of intravenous pressures which in-turn would trigger a sympathetic neuronal reflex vasospasm of the pre-capillary sphincters and a corresponding opening of the normally closed arterio-venous anastomoses (AVAs). This communication would allow entry of the sclerosing agent into the arteriolar side of the circulation resulting in arteriolar occlusion and infarction of the corresponding skin. Similarly, an intravenous administration of sclerosants in the vicinity of defective boundary valves or persistently open AVAs can result in the entry of detergent agents into the arteriolar side of the microvasculature causing an ischemic stellate ulcer.Conclusions: In this first instalment of these two-part series, we review the pathogenic mechanisms of post-sclerotherapy necrosis. In the second instalment, we describe risk minimisation and management strategies.
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Affiliation(s)
- Mina Kang
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Darlinghurst NSW Australia
- Department of Dermatology, St Vincent's Hospital, Darlinghurst, NSW, Australia
- Faculty of Medicine, 7800University of New South Wales, Sydney, NSW, Australia
| | - Anes Yang
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Darlinghurst NSW Australia
- Department of Dermatology, St Vincent's Hospital, Darlinghurst, NSW, Australia
- Faculty of Medicine, 7800University of New South Wales, Sydney, NSW, Australia
| | - Patricia Hannaford
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Darlinghurst NSW Australia
- Department of Dermatology, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - David Connor
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Darlinghurst NSW Australia
| | - Kurosh Parsi
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Darlinghurst NSW Australia
- Department of Dermatology, St Vincent's Hospital, Darlinghurst, NSW, Australia
- Faculty of Medicine, 7800University of New South Wales, Sydney, NSW, Australia
- RinggoldID:541657Sydney Skin and Vein Clinic, Chatswood, NSW, Australia
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Mojarrad P, Barikbin B, Oghazian MB. Can betamethasone prevent Nicolau syndrome when coadministered with penicillin? A case report. Clin Case Rep 2021; 9:e05187. [PMID: 34934500 PMCID: PMC8650753 DOI: 10.1002/ccr3.5187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/23/2021] [Accepted: 11/25/2021] [Indexed: 11/08/2022] Open
Abstract
We present a 33-year-old female patient with Nicolau syndrome (NS) who received one injection of benzathine penicillin and one injection of betamethasone to the right buttock, and one injection of benzathine penicillin to the left. NS was seen only in the left buttock, where it was intramuscularly injected with penicillin benzathine alone.
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Affiliation(s)
- Paria Mojarrad
- Clinical Research Development UnitImam Hasan HospitalNorth Khorasan University of Medical SciencesBojnurdIran
| | - Behnaz Barikbin
- Clinical Research Development UnitImam Hasan HospitalNorth Khorasan University of Medical SciencesBojnurdIran
| | - Mohammad Bagher Oghazian
- Clinical Research Development UnitImam Hasan HospitalNorth Khorasan University of Medical SciencesBojnurdIran
- Department of Internal MedicineFaculty of MedicineNorth Khorasan University of Medical SciencesBojnurdIran
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Al-Sheeb F, Al Mannai G, Tharupeedikayil S. Nicolau Syndrome after Endodontic Treatment: A Case Report. J Endod 2021; 48:269-272. [PMID: 34732322 DOI: 10.1016/j.joen.2021.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/01/2021] [Accepted: 10/20/2021] [Indexed: 01/21/2023]
Abstract
Calcium hydroxide has been used successfully in root canal therapy for many years. However, it can cause serious damage if it is inadvertently displaced into surrounding vital structures, resulting in thrombosis if displaced into blood vessels, damaging connective tissue, and causing skin necrosis. These adverse reactions are known as Nicolau syndrome (NS) or embolia cutis medicamentosa. Very few case reports have been published about these adverse effects of injecting calcium hydroxide beyond the apex during root canal therapy. A 16-year-old female patient was referred to the endodontic department of Hamad Dental Center for assessment after treatment by the maxillofacial surgery department for swelling and tissue necrosis that occurred after endodontic treatment in another clinic. When the patient initially attended the maxillofacial surgery department, she presented with swelling on the left side in the region of the maxillary left first permanent molar. On examination, there was a change in the color of the skin of the left cheek in that area along with some reported paralysis of the left side of her lips. Analgesics and antibiotics had already been prescribed at the referring clinic. Two weeks later, the patient developed a necrotic patch of skin on the same area. Subsequent evaluation at the endodontic department of Hamad Dental Center led to a diagnosis of NS. NS is a very rare iatrogenic condition. Displacing calcium hydroxide beyond the apex might increase the chance of NS. Clinicians should avoid overinstrumentation and forced injection of calcium hydroxide to prevent NS.
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Affiliation(s)
- Fatima Al-Sheeb
- Hamad Dental Center, Hamad Medical Corporation, Doha, Qatar.
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Sasmal PK, Sahoo A, Singh PK, Vs V. Nicolau Syndrome: An Unforeseen Yet Evadable Consequence of Intramuscular Injection. Surg J (N Y) 2021; 7:e62-e65. [PMID: 34056105 PMCID: PMC8149156 DOI: 10.1055/s-0041-1728652] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 02/22/2021] [Indexed: 11/06/2022] Open
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.
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Affiliation(s)
- Prakash K Sasmal
- Department of Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Ankit Sahoo
- Department of Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Pradeep Kumar Singh
- Department of Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Vikram Vs
- Department of Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
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Kouamé YGS, Yaokreh JB, Sounkeré M, Tembely S, Ajoumissi IT, N'goran KE, Thomas AH, Hervé Odehouri KT, Kouamé DB, Ouattara O. Nicolau syndrome after intramuscular benzathine penicillin injection. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2021. [DOI: 10.1016/j.epsc.2020.101597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Maia LDA, Pereira O, Marta R, Costa J, Batista A, David Costa J, Macedo F, Fraga J, Vilela C. Nicolau syndrome due to a traumatic finger injury with a needle : a case report with an exclusive photographic documentation. Case Reports Plast Surg Hand Surg 2020; 7:88-93. [PMID: 32939362 PMCID: PMC7470083 DOI: 10.1080/23320885.2020.1805325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Introduction Nicolau syndrome, also known as livedo-like dermatitis or embolia cutis medicamentosa, is a rare complication usually after intra-muscular or intra-articular injection of various drugs. It is difficult to find photographic documentation of this syndrome from the initial stages due to its rarity and unpredictable evolution. Case presentation We report the case of a 54-year-old Portuguese woman who developed Nicolau Syndrome after a traumatic finger injury with a sewing needle. She developed an ulcer and cutaneous necrosis. She was treated with surgical debridement, antibiotic, analgesics and sterile dressings. The ulcer healed completely within 18 weeks with scarring. Conclusions Although Nicolau syndrome develops very rarely, it is an important cause for morbidity. It is an iatrogenic condition. The Nicolau Syndrome following a traumatic injury with a needle without drugs, as far as we know, has never been reported in the published literature especially with photographic records from the beginning of the process.
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Affiliation(s)
- Luis de Almeida Maia
- Department of Orthopaedics and Traumatology, Hospital Senhora da Oliveira, Guimarães, Portugal
| | - Olga Pereira
- Department of Dermatology, Hospital Senhora da Oliveira, Guimarães, Portugal
| | - Ricardo Marta
- Department of Orthopaedics and Traumatology, Hospital Senhora da Oliveira, Guimarães, Portugal
| | - Joana Costa
- Department of Orthopaedics and Traumatology, Hospital Senhora da Oliveira, Guimarães, Portugal
| | - Ana Batista
- Department of Orthopaedics and Traumatology, Hospital Senhora da Oliveira, Guimarães, Portugal
| | - João David Costa
- Department of Orthopaedics and Traumatology, Hospital Senhora da Oliveira, Guimarães, Portugal
| | - Fernando Macedo
- Department of Orthopaedics and Traumatology, Hospital Senhora da Oliveira, Guimarães, Portugal
| | - Jose Fraga
- Department of Orthopaedics and Traumatology, Hospital Senhora da Oliveira, Guimarães, Portugal
| | - Carlos Vilela
- Department of Orthopaedics and Traumatology, Hospital Senhora da Oliveira, Guimarães, Portugal
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Raju B, Ashraf O, Jumah F, Appaji Gowda NM, Gupta G, Sun H, Nanda A. Nicolau Syndrome, Masquerader of Postinjection Sciatic Nerve Injury: Case Report and Review of Literature. World Neurosurg 2020; 143:51-55. [PMID: 32679363 DOI: 10.1016/j.wneu.2020.07.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 07/03/2020] [Accepted: 07/05/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Sciatic nerve injury after inadvertent intramuscular gluteal injection is a well-described entity. We have presented a case of a rare and probably underdiagnosed pathological entity, Nicolau syndrome, which can be confused with injection palsy. CASE DESCRIPTION We report the case of a 13-year-old boy who had presented with foot drop and urinary and fecal incontinence after an intramuscular injection of benzathine penicillin in the left gluteal region. On examination, the patient had multiple ecchymoses over the left gluteal region and back of the thigh, mild swelling of the left lower limb, and left foot drop. Meticulous examination also revealed a subtle weakness of the opposite limb. Nerve conduction studies revealed axonopathy involving multiple bilateral lower limb nerves. These unusual neurological-dermatological signs and electrophysiological findings raised the concern for an alternative pathology, which was later diagnosed as Nicolau syndrome. The patient experienced clinical and electrophysiological recovery after a course of oral steroids and physiotherapy during the next few months. CONCLUSIONS Before diagnosing injection sciatic nerve injury, the possibility of medically treatable Nicolau syndrome should be considered. Neurosurgeons' familiarity with this pathology and a timely diagnosis is essential to plan appropriate treatment strategies.
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Affiliation(s)
- Bharath Raju
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School and University Hospital, New Brunswick, New Jersey, USA; Department of Neurosurgery, Kempegowda Institute of Medical Sciences and Research Institute, Bengaluru, India.
| | - Omar Ashraf
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School and University Hospital, New Brunswick, New Jersey, USA
| | - Fareed Jumah
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School and University Hospital, New Brunswick, New Jersey, USA
| | - Naveen Mandya Appaji Gowda
- Department of Neurosurgery, Kempegowda Institute of Medical Sciences and Research Institute, Bengaluru, India
| | - Gaurav Gupta
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School and University Hospital, New Brunswick, New Jersey, USA
| | - Hai Sun
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School and University Hospital, New Brunswick, New Jersey, USA
| | - Anil Nanda
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School and University Hospital, New Brunswick, New Jersey, USA
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