Вы находитесь на странице: 1из 3

Case report

Nicolau syndrome after lidocaine injection and cold application: a rare complication of breast core needle biopsy
Andres Garca-Vilanova-Comas1, MD, PhD, Carlos Fuster-Diana1, MD, PhD, Marisa Cubells-Parrilla2, MD, PhD, Mara Desamparados Perez-Ferriols3, MD, PhD, 4 1 Ana Perez-Valles , MD, PhD, and Jose Vicente Roig-Vila , MD, PhD

1 Surgery Department, 2Radiology Department, 3Dermatology Department, 4 Pathology Department, Consorcio Hospital, General Universitario de Valencia, Valencia, Spain

Correspondence s Andre Garca-Vilanova-Comas, MD, PhD Surgery Department Consorcio Hospital General Universitario de Valencia Av. Tres Cruces 2 46014 - Valencia (Spain) E-mail: andres.garcia-vilanova@uv.es

Introduction Nicolau syndrome (embolia cutis medicamentosa or livedoid dermatitis) was rst described by Freuhdental and Nicolau in 1924 and 1925. It is dened as local aseptic cutaneous, and sometimes muscular, necrosis observed at the injection site of an intramuscular preparation. Patients typically present with intense pain at the injection site with pallor owing to local reex vasospasm, followed by an erythematous maculae evolving after 24 h into a livedoid violaceous patch with dendritic extensions. This patch becomes hemorrhagic and then necrotic. The necrosis often involves the muscle and is demarcated over 12 weeks.1,2 The eschar eventually sloughs, and the underlying ulcer heals over months, leaving an atrophic scar devoid of anexal structures. The evolution is unpredictable, and the syndrome has been associated with morbid complications such as widespread cutaneous necrosis, transitory or permanent ischemia of the ipsilateral limb, various neurologic complications, isolated muscular necrosis without skin lesions and superimposed infection.3,4 The syndrome has also been described in association with an intramuscular injection of antirheumatic preparations containing phenylbutazone variably associated with other anti-inammatory agents, local anesthetics, antihistamines, corticosteroids and vitamin B complexes.5 It has also been described after injection of sulfonamides, benzathine penicillin,6 procaine penicillinG, pyrazolone,7 chlorpromazine,
International Journal of Dermatology 2011, 50, 7880

camphorquinine combinations, phenobarbitone, recombinant interferon alfa,8 interferon beta,9 iodine sclerosing substances, vaccines (varicella and DTP [Diphteria, Tetanus, Pertussis])10 and a mixture of sedatives. Histologic ndings include thrombosis of vessels in the reticular dermis. The resultant necrosis often involves the muscles, and secondary bacterial infection may occur. Clinical case We present the case of a 46-year-old patient with a past medical history signicant for hysterectomy and amigdalectomy. During a breast-screening programme, a region of brilar retraction was detected by mammography. It was located in the interquadratic upper line of her left breast. Given the highly likelihood of malignancy, she was sent for a diagnostic biopsy by the radiology service. Core needle biopsy was performed. First, the skin was inltrated with 1% lidocaine (without vasoconstrictor) in the area of the biopsy. Then, the needle was inserted, and our patient noticed intense pain during the core needle biopsy. Immediately, ice was applied as a local analgesic. Later, an area of red dark color appeared around the biopsy site. She was treated with antibiotics (amoxicillyn/clavulanic acid) and nonsteroidal antinammatory agents. She was referred to the dermatology service, who started treatment with topical betamethasone dipropionate gentamicin. Despite this treatment, a black region
2011 The International Society of Dermatology

78

Garca-Vilanova-Comas et al.

Nicolau syndrome after lidocaine and cold

Case report

79

appeared in 24 h. The dermatologists then applied an alginate dressing. The result of the core needle biopsy was breast parenchyma without tumoral cells. Two weeks later, the patient was admitted to the surgical service for evaluation of the cutaneous lesion. Examination revealed a green, necrotic, crusted, indurated plaque (5 3 cm) with welldened limits, rmly adherent to the underlying tissue with a slight region of erythema surrounding the plaque. An indurated area was felt under the lesion. A bacteriologic culture of a specimen from the ulcer surface underneath the crust was negative (Fig. 1). A mammary ultrasound was performed but showed only skin and subcutaneous edema. No hematomas or mammary collections were detected. As we had a high suspicion of advanced breast carcinoma, we performed a cutaneous biopsy, but histology of the cutaneous fragment only showed cutaneous necrosis and an abscess without neoplastic ndings. Although the core biopsy did not reveal a malignancy, the breast image was suspicious, so the patient underwent pre-operative tests for open biopsy. The patient was surgically treated by extirpation of the plaque of crusted cutaneous necrosis and underlying subcutaneous and breast tissue, including the area suspicious for breast cancer. A new sample was also submitted for bacteriology. The skin fragment showed nonspecic inammatory changes. No evidence of malignancy or vasculitis was observed (Fig. 2). The mammary sample (55 cm in diameter) showed a brous whitish area on macroscopic examination. Microscopically, we observed subcutaneous and intraparenchymal fat necrosis, with areas of brosis, hyalinosis and abscess. No evidence of malignancy was found. Microbiology revealed Enterococcus faecalis, Klebsiella oxytoca and Estalococo aureus, Staphylococcus aureus within the sample.

Figure 2 Fat intraparenchimatous necrosis (20)

Discussion Although several theories have been suggested, the pathogenesis of Nicolau syndrome is poorly understood. Periarterial or perineural injection has been proposed to cause severe local pain with sympathetic nerve stimulation and vasospasm leading to ischemia or cutaneous necrosis. Intra-arterial injection of particular drugs also has been suggested to cause marked inammation or embolic occlusion of the small arteries, possibly leading to progressive necrosis of the intima followed by destruction of the arterial wall and subsequent necrosis of the skin. The main feature of all these suggested mechanisms is occlusion of a peripheral arterial vessel. In our case, subcutaneous or intraparenchymal injection rather than intramuscular administration was likely a determining factor. Another important factor is the drug injected, where we used lidocaine. Lidocaine is commonly considered a vasodilator. However, there are two reported cases of peripheral vasoconstriction possibly caused by topical application of lidocaine, so there is a potential risk of vasospasm with lidocaine administration.11 There is no specic treatment for Nicolau syndrome. Treatment depends on the extent of the necrosis and ranges from topical to surgical. Conservative treatment with analgesics and dressings is generally recommended for limited cases. Tissue damage is not reversible, but rapid vasoactive therapy with subcutaneous heparin and oral pentoxiline is reportedly benecial.4 The necrotic ulcer usually heals in several months, leaving an atrophic scar. Sometimes multiple debridements and partial thickness skin grafts are required, and computed tomography scan or magnetic resonance imaging have been recommended to dene the extent of the lesion. Plexus block,
International Journal of Dermatology 2011, 50, 7880

Figure 1 Green necrotic crusted indurated plaque


2011 The International Society of Dermatology

80

Case report

Nicolau syndrome after lidocaine and cold

Garca-Vilanova-Comas et al.

heparin, arteriotomy and extraction of the clot have been favorably discussed.3 Prevention is very important. Intramuscular injections should be performed only after having aspirated with the syringe to ensure extra-vascular injection of the drug.12 The Z-track method of intramuscular injection could minimize subcutaneous irritation by blocking the needle track after injection; this has been recommended as a standard procedure.13 Our patient applied an ice pack to calm the pain. However, exposure of the injection site to the cold probably increased the acute local vasospasm. There are previous reports of a patient with NS (Nicolau sndrome) caused by diclofenac injection,1316 including one that occurred after applying a cold compress. In that case, the necrosis progressed despite conservative therapy, and surgical reconstruction was necessary.16 In our case, the necrotic plaque was included in the stereotactic surgical extirpation of the underlying breast lesion. Therefore, no residual scar was left behind. Although the buttocks are the most frequent site,13 NS has also been reported on the shoulder, thigh, knee17 and ankle. We have not found any reports in breast after core needle biopsy. Breast core needle biopsy is one of the most commonly used diagnostic methods in breast pathology. In light of this, radiologists and physicians diagnosing breast pathology should be aware of this complication and take preventive measures. Conclusions Although Nicolau syndrome is a rare adverse reaction, clinicians should be aware of this complication. Related drugs should be administered orally if possible. Furthermore, if a patient develops immediate intense pain and an erythematous reticular patch following drug injection, local cold application should be avoided to minimize the risk of rapid necrosis. References
1 Faucher L, Marcoux D. What syndrome is this? Nicolau syndrome Pediatric Dermatol 1995; 12: 187190. 2 Stiehl P, Weissbach G, Schrotter K. Das NicolauSyndrome. Schweiz Med Wochenshr 1971; 99: 266269.

3 Corazza M, Capozzi O, Virgili A. Five cases of livedolike dermatitis (Nicolaus Syndrome) due to bismuth salts and other non-steroidal anti-inammatory drugs. J Eur Acad Dermatol Venereol 2001; 15: 585588. 4 Rufeux PH, Salomon D, Saurat J. Livedo-like dermatitis (Nicolaus syndrome) a review of three cases. Dermatology 1996; 193: 368371. 5 Kunzi T, Ramstein C, Pirovino M. Circumscribed skin necrosis following intramuscular injection (embolia cutis medicamentosa). Praxis (Bern 1994) 1995; 84: 640643. 6 Gebert K. Embolitic lumbar artery occlusion following benzathinpenicillin (penduran). A case contribution to Nicolau syndrome in adults. Psichyatr Neurol Med Psychol (Leipz) 1980; 32: 443446. 7 Luton K, Garcia C, Poletti C, Koester G. Nicolau Syndrome: three cases and review. Int J Dermatol 2006; 45: 13261328. 8 Sonntag M, Hodzic-Avdagic N, Bruch-Gerharz D, Neumann NJ. Embolia cutis medicamentosa after subcutaneous injection of pegylated interferon-alpha. Hautarzt 2005; 56: 968969. 9 Koontz D, Alshekhlee A. Embolia cutis medicamentosa following interferon beta injection. Mult Scler 2007; 13: 12031204. 10 Nagore E, Torrelo A, Gonzalez-Medeiro I, Zambrano A. Livedoid skin necrosis (Nicolau syndrome) due to triple vaccine (DTP) injection. Br J Dermatol 1997; 137: 10301031. 11 Azma T, Okida M. Does lidocaine provoke clinically signicant vasospasm? Acta Anaesthesiol Scand 2003; 47: 11741175. 12 Kohler LD, Schwedler S, Worret WI. Embolia cutis medicamentosa. Int J Dermatol 1997; 36: 197. 13 Lie C, Leung F, Chow SP. Nicolau syndrome following intramuscular diclofenac administration: a case report. J Orthop Surg 2006; 14: 104107. 14 Ezzedine K, Vadoud-Seyedi J, Heenen M. Nikolau syndrome following diclofenac administration. Br J Dermatol 2004; 150: 367399. 15 Sarifakioglu E. Nicolau syndrome after diclofenac injection. J Eur Acad Dermatol Venereol 2007; 21: 266267. 16 Senel E, Ada S, Gle AT, Caglar B. Nicolau syndrome aggravated by cold application after i.m. diclofenac. J Dermatol 2008; 35: 1820. 17 Beissert S, Presser D, Rutter A, et al. Embolia cutis medicamentosa (Nicolau syndrome) after intra-articular injection. Hautarzt 1999; 50: 214216.

International Journal of Dermatology 2011, 50, 7880

2011 The International Society of Dermatology

Вам также может понравиться