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Nicolau's syndrome is a rare complication after the intramuscular administration of certain drugs. This is an iatrogenic disease where the injected substance unintentionally enters the lumen of the artery. How is Nicolau's syndrome manifested and how is it treated?

Nicolau's syndromeis an example of iatrogenic syndrome, a condition that develops as a result of incorrect treatment. Iatrogenic disease can be the result of both medical errors and even the doctor's approach to the patient.

Nicolau's syndrome can occur if a substance is injected too quickly, under too much pressure, too much, or repeatedly injected into the same site.

Sometimes the patient's self-suggestion arose as a result of the doctor's words, e.g. severe fear, leads to disease symptoms. In the case of Nicolau's syndrome, the aforementioned medical error is the penetration of a substance (crystals or suspension) injected intramuscularly - in most cases into the buttock, although it happens that Nicolau's syndrome occurs after injection into the joint, under the skin, and even after sclerotherapy - into the lumen of the artery.

Symptoms of Nicolau's syndrome

  • severe pain at the injection site, and even throughout the buttock or further in the limb, during or immediately after injection of the substance; in light cases only skin hypersensitivity
  • pale skin - when injected into the buttock, pallor may also cover the other buttock and the lower abdomen and one or both lower limbs
  • constriction of blood vessels
  • embolic symptoms: no pulse in the peripheral arteries, in the dorsal arteries of the foot, popliteal, femoral - leading to necrosis of the foot and lower leg
  • cooling down the body in the area where the injection was made
  • bluish discoloration of the skin around the injection site, which is a symptom of ischemia
  • tissue necrosis
  • bloody stools
  • hematuria
  • neurological complications such as sciatic nerve palsy, severe pain along the sciatic nerve radiating to the lower abdomen and the other lower limb
  • transverse damage to the spinal cord - especially in children - leading to tissue necrosis

Drugs that may cause Nicolau's syndrome

  • antibiotics such as penicillins, tetracycline, gentamicin, streptomycin
  • corticosteroids such as: dexamethasone, parametasone
  • antihistamines, e.g. hydroxyzine
  • non-steroidal anti-inflammatory drugs, e.g. ibuprofen, diclofenac, ketoprofen
  • antiepileptic and antipsychotic drugs, e.g. chlorpromazine
  • drugs containing bismuth - used, for example, to treatHelicobacter pylori
  • alpha interferon
  • buprenorphine
  • hyaluronic acid
  • local anesthetics, e.g. lidocaine
  • vitamins, e.g. vitamin K, vitamin B
  • DTP vaccine, i.e. against diphtheria, tetanus and pertussis

Diagnosis of Nicolau's syndrome

Usually, the characteristic symptoms that appear immediately after the injection, and often during it, are enough to make a diagnosis. The confirmation will be:

  • blood count test showing leukocytosis, i.e. an increased white blood cell count, but with normal eosinophil levels
  • magnetic resonance imaging - showing significant swelling and inflammation of the tissues in the area of ​​injection
  • no pulse in peripheral arteries

Treatment and prognosis for Nicolau's syndrome

Nicolau's syndrome can be fatal within days, even hours. If you suspect that this has occurred, first and if possible, stop the injection immediately and withdraw the needle from your body. Treatment consists of removing necrotic lesions, administering painkillers and steroid ointments. At best, the wound will heal, the scarring will remain, but the limb will be fully functional. Advanced necrosis requires surgery, amputation, or transplant. Pentoxifylline is also administered to increase blood flow, and heparin is an anticoagulant. Often, however, there is a need to implement vigorous shock management.

Worth knowing

What a doctor should remember to avoid Nicolau's syndrome

  • insert the needle into the upper outer quadrant of the buttock
  • the needle should be adjusted in length to the patient's weight so that it hits the muscle; Before starting the drug administration, perform an aspiration test to confirm the correct needle position
  • In one injection we give a maximum of 5 ml of fluid, and if more is required, a second injection must be made in a different place or the form of administration should not be given up at all

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