Embolia cutis medicamentosa (Nicolau syndrome)

Extract

A 76-year-old woman presented with an indurated and painful, ecchymotic plaque on her right buttock 48 h after an intramuscular injection of ketorolac tromethamine for coxarthrosis (Figure 1). She stated that injection had been extremely painful, with initial blanching at the injection site. At presentation, blood results, including creatinine kinase, were unremarkable. Superficial ultrasonography showed diffuse oedema, with sparing of the muscle and no fluid collections. Bacteriological culture of swabs grew only resident flora. Oral cefotaxime (400 mg/day for 8 days) plus nimesulide β-cyclodextrin did not prevent progressive necrotizing so plastic surgery was performed, the lesion healed in 2 months with a depressed scar.

Embolia cutis medicamentosa is a rare, still unexplained complication of injection of several drugs, characterized by cutaneous, subcutaneous and even muscular aseptic necrosis in a livedoid pattern.¹

First described by Freudenthal and Nicolau,² it typically presents with pallor, owing to a local reflex vasospasm, and pain, rapidly followed by erythema, livedoid/haemorrhagic patch, blistering and variable features of necrosis.