Embolia cutis medicamentosa T88.83

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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Synonym(s)

Dermite lividoid; livedoartige dermatitis; livedo-like dermatitis; Nicolau Syndrome; syndrome livédoid paralytic

History
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Freudenthal, 1924; Nicolau, 1925

Definition
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Rare, circumscribed (in the injection area), painful, dendritic, infarct-like, sharply defined zosteriform skin necroses after intramuscular, rarely after intra-articular or subcutaneous injections.

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Etiopathogenesis
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Intra-arterial, possibly para-arterial injection of drugs to be injected intramuscularly. Pathogenetically, the intra-arterial injection causes vasospasm and fibrinoid necrosis of arterioles and capillaries with thrombosis of the terminal tract. Potentially triggering drugs:

Depotpenicillins
Phenylbutazone-containing antirheumatic drugs
Interferons
Vaccines
Glatiramer acetate (immunomodulator in MS).

Clinical features
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Minutes to a few hours after the i.m. injection painful, board-like infiltration with livedo racemosa-like skin markings (bizarre, tendril-like figures). Healing with hyperpigmentation. Central demarcation with formation of flat to sunken hemorrhagic necroses possible after 24-72 hours. Repulsion of the hemorrhagic scab. Development of deep ulcerations which heal with bizarrely shaped atrophic scars.

Stage I: Edema extending beyond the injection area with inflammatory infiltration without necrosis.
Stage II: Strong inflammatory reaction, macroscopically still no necrosis.
Stage III: Necrosis of skin and/or muscles.
Stage IV: Additional necrosis of organs of the small pelvis.

Differential diagnosis
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Syringe abscess, livedo racemosa.

External therapy
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At the beginning of the therapy trial with glucocorticoid creams such as 0.1% triamcinolone cream(e.g. Triamgalen, R259 ) or 0.05% betamethasone V-lotio(e.g. Betnesol V, R030 ) or bland-drying with pasta zinci. After demarcation, removal of the necroses, wound cleansing, granulation-promoting measures, see below wound treatment.

Internal therapy
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Antiphlogistic therapy with ibuprofen (e.g. ibuprofen stada, 2-3 times/day 200 mg p.o.). At the beginning, vasodilating agents such as pentoxifylline (e.g. Trental 2 times/day 600 mg p.o.), nicotinic acid (Merz Spezial Dragees N 3 times/day 2-3 Drg. p.o.) or papaverine derivatives such as moxaverine (e.g. Kollateral forte Drg., 2-3 times/day 1 Drg. p.o.) can be tried.
Pain therapy with paracetamol (e.g. Ben-u-ron Tbl.) or possibly tramadol (e.g. Tramal Trp.).
If necessary, prophylactic systemic broad-spectrum antibiotics, e.g. with Ofloxacin (e.g. Tavanic) 2 times/day 100-200 mg p.o., in case of superinfection antibiotics after antibiogram.

Literature
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Beissert et al (1999) Embolia cutis medicamentosa (Nicolau syndrome) after intra-articular injection. dermatologist 50: 214-216
Cherasse A et al (2003) Nicolau's syndrome after local glucocorticoid injection. Joint Bone Spine 70: 390-392
Freudenthal W (1924) Local embolic bismogenol exanthema. Arch Dermatol Syph 147: 155-160
Littmann K, Albrecht KH, Judge HJ, Eigler FW (1984) Embolia cutis. Dtsch med Wschr 109: 800-805
Müller CSL et al (2016) Diagnostic and histological features of cutaneous vasculitis/vasculopathies. Act Dermatol 42: 286-301
Nicolau S (1925) Dermatite livédoide et gangreneuse de la fesse consécutive aux injections intramusculaires dans la syphilis Speaking of a case of arterial bismuth embolism. Ann Mal Vén 20: 321-339