A Rare Case of Nicolau’s Syndrome (Embolia Cutis Medicamentosa) Following Intramuscular Diclofenac Sodium Injection in a Young Adult

Abstract

Nicolau syndrome (embolia cutis medicamentosa) is a condition where we see variable degrees of tissue necrosis including the skin and deeper tissues, due to an iatrogenic cause, intramuscular, subcutaneous, intra-articular injections, could be some of them. It occurs due to intravascular inoculation leading to crystal embolization causing thrombotic occlusion, vasospasm, and marked inflammation and surrounding necrosis. Here, we present a case of a 35-year-old gentleman who presented to us with bluish-purple discoloration of the skin followed by a necrotic patch and ulceration with multiple hyperpigmented spots over the back and lower limb post intramuscular diclofenac sodium injection. Routine investigation showed neutrophilia and thrombocytosis with increased creatinine. A diagnosis of Nicolau’s syndrome (embolia cutis medicamentosa) was made clinically, which was confirmed by histopathology following biopsy. Adequate surgical debridement and a combination therapy of analgesics, intravenous antibiotics, intravenous anticoagulants, and vasoactive therapy were administered. Split thickness skin grafting was done once the wound was healthy with rich granulation tissue, after 4 weeks of index surgery in this case. Patient recovered uneventfully.