An Exceptional Cause of Acute Limb Ischemia: Nicolau Syndrome-Single-Center Experience with 4 Cases

Abstract

Background: Causes of acute limb ischemia are classically mainly emboli and thrombosis. Nicolau syndrome is a very rare complication of intramuscular injection presumed to be related to the inadvertent intravascular injection. It was first reported after intramuscular injection of bismuth salt, but it can occur as a complication of various other drugs. Acute limb ischemia is one of its severe outcomes but is rarely encountered and reported.

Methods: Patients admitted with the final diagnosis of Nicolau syndrome in our institution in 3 years (2016 2017 and 2018) are reviewed in terms of etiology, clinical presentation, management, and outcome.

Results: We present here 4 cases of Nicolau syndrome that lead to acute limb ischemia and with the same outcome: limb or fingers loss; there were 2 upper extremities for 2 women secondary to diclofenac and dexamethasone intramuscular administration and 2 lower extremities for 2 men in relation with Benzathine Penicillin intramuscular administration. The medical and surgical management that we attempted did not prevent this severe outcome.

Conclusions: Nicolau syndrome should be considered when looking for rare etiologies of acute limb ischemias.