Nicolau's Syndrome Complicated by Atypical Necrotizing Fasciitis

267 We read with interest the article by Kim and colleagues [1] entitled “Nicolau’s syndrome after intramuscular injection: 3 cases.” Recently, we published a case report in The Journal of Dermatology about embolia cutis medicamentosa [2]. Herewith, we highlight the lethal potential and the possible serious complications of this syndrome by reporting a case of complicated life-threatening Nicolau’s syndrome. A 44-yearold white male patient was referred to our department with severe thigh pain and a painful cutaneous necrotic spot in the lower outer quadrant of the right buttock (Fig. 1). The patient reported that after an intra-muscular injection of diclofenac 10 days earlier, the gluteal region showed swelling followed by edema, discoloration, and erythema that evolved to a necrotic spot. The patient was drug-addicted and presented several comorbidities: viral (hepatitis B virus and hepatitis C virus) hepatic cirrhosis (Child-Pugh class A5), severe obesity (body mass index, 44.4) and uncompensated type II diabetes complicated by recurrent cutaneous pustulosis (Staphylococcus aureus and Streptococcus mitis). A physical examination revealed a 6×5 cm necrotic spot in the lower outer quadrant of the right buttock with edema and erythema of the posterior thigh. The patient was apyretic at the time of hospital admission; no increase in body temperature was observed during the hospital stay or the 3-month postoperative follow-up. A computerized tomography scan showed a gluteal 13×7 cm abscess involving the gluteus maximus muscle and the subcutaneous tissue, millimetric cutaneous gas bubbles in the right buttock and fat stranding with thickening of the skin, subcutaneous tissue, and fascia in the posterolateral thigh (Fig. 2). The diagnosis of Nicolau’s syndrome complicated by abscess and necrotizing fasciitis of the posterior thigh was made. The patient underwent drainage of the abscessed cavity, followed by surgical debridement of the necrotic tissue (Fig. 3). Microbiological investigation demonstrated a penicillin−and cephalosporin−resistant Staphylococcus aureus infection that was treated with teicoplanin. Nicolau’s syndrome is a rare complication that may occur after intra-muscular injection of several drugs [2,3]. Patients often describe immediate pain that increases after the injection, followed by edema, discoloration, net-like erythema, a livedoid violaceous patch, and ulceration. Tissue necrosis may only involve the cutis and subcutis or even extend deep to the fascia and muscle. The treatment depends both on the timing of the diagnosis and the symptoms. In most cases, embolia cutis medicamentosa presents with only local necrosis; therefore, subcutaneous heparin injections LETTERS