Abstract
Nicolau syndrome is a rare complication of intramuscular injection that leads to local ischemic necrosis of the skin and adipose tissue. In this paper, we discuss etiologies, risk factors, and treatment options for gluteal Nicolau syndrome referring to patients treated in our hospital. Our study includes 17 women who visited our clinic with symptoms of gluteal necrosis secondary to intramuscular injection. The following variables were taken into account: injection site, drug administered, frequency of injections, the person who administered the injections, needle size, and needle tip color. Magnetic resonance images obtained in the aftermath of intramuscular injection application were carefully analyzed for presence of necrosis, cyst formation and the thickness of the gluteal fat tissue layer. Drugs that had been received in intramuscular injection were exclusively non-steroidal anti-inflammatory drugs. Mean patient BMI was 41.8 (all patients were considered as obese), and mean gluteal fat thickness was 54 mm. Standard length of needles (3.8 cm) had been used in procedures. The wounds were treated with primary closure in 11 patients and with local flap therapy in 6 patients. The observed necrosis was a consequence of misplaced gluteal injection, where drugs were injected into the adipose tissue instead of the muscle due to the extreme thickness of the fat layer, on one hand, and the inappropriate length of standard needles, on the other hand. Intramuscular injection should be avoided in obese patients whenever possible: if it is necessary, proper injection technique should be used.
Highlights
Intramuscular injection is used as a technique of choice for application of drugs in many treatment protocols in order to achieve quick and effective response
Nicolau syndrome is a rare complication of intramuscular injection that usually presents with pain at the injection site, hyperemia, skin discoloration, redness, abscess formation, and local ischemic necrosis involving the skin and adipose tissue
If the needle tip does not reach the muscle, which often occurs in overweight patients, the administered drug may remain within the adipose tissue
Summary
Intramuscular injection is used as a technique of choice for application of drugs in many treatment protocols in order to achieve quick and effective response. The best-known and most severe complication of this procedure is a sciatic nerve injury; an abscess and/or tissue necrosis may develop at the injection site[1,2,3,4,5]. Nicolau syndrome (livedoid dermatitis, embolia cutis medicamentosa) is a rare complication of intramuscular injection that usually presents with pain at the injection site, hyperemia, skin discoloration, redness, abscess formation, and local ischemic necrosis involving the skin and adipose tissue. The drugs most commonly causing tissue necrosis include phenylbutazone, local anesthetics, antihistamines, anti-inflammatory agents, corticosteroids, and penicillins [4,5,6,7,8,9,10,11,12]. Mehmet Dadaci, et al.: Nicolau Syndrome after Intramuscular Injection of Non-Steroidal Anti-Inflammatory Drugs (NSAID). The present study discusses treatment methods that we employed at our hospital for patients with Nicolau syndrome in the gluteal region, as well as possible etiologies and risk factors for the development of this syndrome
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