array:23 [
  "pii" => "S0365059623002064"
  "issn" => "03650596"
  "doi" => "10.1016/j.abd.2022.06.010"
  "estado" => "S300"
  "fechaPublicacion" => "2024-01-01"
  "aid" => "841"
  "copyright" => "Sociedade Brasileira de Dermatologia"
  "copyrightAnyo" => "2023"
  "documento" => "simple-article"
  "crossmark" => 1
  "subdocumento" => "crp"
  "abierto" => array:3 [
    "ES" => false
    "ES2" => false
    "LATM" => false
  ]
  "gratuito" => false
  "lecturas" => array:1 [
    "total" => 0
  ]
  "Traduccion" => array:1 [
    "pt" => array:18 [
      "pii" => "S2666275223002382"
      "issn" => "26662752"
      "doi" => "10.1016/j.abdp.2023.09.019"
      "estado" => "S300"
      "fechaPublicacion" => "2024-01-01"
      "aid" => "841"
      "copyright" => "Sociedade Brasileira de Dermatologia"
      "documento" => "simple-article"
      "crossmark" => 1
      "subdocumento" => "crp"
      "abierto" => array:3 [
        "ES" => false
        "ES2" => false
        "LATM" => false
      ]
      "gratuito" => false
      "lecturas" => array:1 [
        "total" => 0
      ]
      "pt" => array:10 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">Cartas &#8208; Caso cl&#237;nico</span>"
        "titulo" => "S&#237;ndrome de Nicolau extensa ap&#243;s diclofenaco s&#243;dico intramuscular"
        "tienePdf" => "pt"
        "tieneTextoCompleto" => "pt"
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "123"
            "paginaFinal" => "125"
          ]
        ]
        "contieneTextoCompleto" => array:1 [
          "pt" => true
        ]
        "contienePdf" => array:1 [
          "pt" => true
        ]
        "resumenGrafico" => array:2 [
          "original" => 0
          "multimedia" => array:7 [
            "identificador" => "fig0005"
            "etiqueta" => "Figura 1"
            "tipo" => "MULTIMEDIAFIGURA"
            "mostrarFloat" => true
            "mostrarDisplay" => false
            "figura" => array:1 [
              0 => array:4 [
                "imagen" => "gr1.jpeg"
                "Alto" => 1972
                "Ancho" => 1508
                "Tamanyo" => 355917
              ]
            ]
            "descripcion" => array:1 [
              "pt" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Bolhas viol&#225;ceas&#44; retiformes com &#225;reas de descolamento cut&#226;neo em coxa e perna&#46; Notam&#8208;se tamb&#233;m &#225;reas de necrose com halo eritematoso&#46; &#40;B&#41; Progress&#227;o das &#225;reas de necrose sete dias ap&#243;s in&#237;cio do quadro</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "Rafael Oliveira Amorim, Alana Lu&#237;sa Calixto Carlos da Silva, Camila Arai Seque, Adriana Maria Porro"
            "autores" => array:4 [
              0 => array:2 [
                "nombre" => "Rafael Oliveira"
                "apellidos" => "Amorim"
              ]
              1 => array:2 [
                "nombre" => "Alana Lu&#237;sa Calixto Carlos da"
                "apellidos" => "Silva"
              ]
              2 => array:2 [
                "nombre" => "Camila Arai"
                "apellidos" => "Seque"
              ]
              3 => array:2 [
                "nombre" => "Adriana Maria"
                "apellidos" => "Porro"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "pt"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S0365059623002064"
          "doi" => "10.1016/j.abd.2022.06.010"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => false
            "ES2" => false
            "LATM" => false
          ]
          "gratuito" => false
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059623002064?idApp=UINPBA00008Z"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666275223002382?idApp=UINPBA00008Z"
      "url" => "/26662752/0000009900000001/v1_202401040746/S2666275223002382/v1_202401040746/pt/main.assets"
    ]
  ]
  "itemSiguiente" => array:18 [
    "pii" => "S0365059623001903"
    "issn" => "03650596"
    "doi" => "10.1016/j.abd.2023.03.003"
    "estado" => "S300"
    "fechaPublicacion" => "2024-01-01"
    "aid" => "825"
    "copyright" => "Sociedade Brasileira de Dermatologia"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "crp"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:1 [
      "total" => 0
    ]
    "en" => array:10 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Letter - Clinical</span>"
      "titulo" => "Lipschutz&#8217;s vulvar ulcer in an adolescent after Pifzer COVID-19 vaccine"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "125"
          "paginaFinal" => "126"
        ]
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:8 [
          "identificador" => "fig0005"
          "etiqueta" => "Figure 1"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr1.jpeg"
              "Alto" => 1272
              "Ancho" => 955
              "Tamanyo" => 163931
            ]
          ]
          "detalles" => array:1 [
            0 => array:3 [
              "identificador" => "at0030"
              "detalle" => "Figure "
              "rol" => "short"
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Fibrinous kissing ulcers on the vulva&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Juan-Manuel Mor&#243;n-Oca&#241;a, Ana-Isabel Lorente-Lavirgen, Isabel-Mar&#237;a Coronel-P&#233;rez, Mar&#237;a-Luisa Mart&#237;nez-Barranca"
          "autores" => array:4 [
            0 => array:2 [
              "nombre" => "Juan-Manuel"
              "apellidos" => "Mor&#243;n-Oca&#241;a"
            ]
            1 => array:2 [
              "nombre" => "Ana-Isabel"
              "apellidos" => "Lorente-Lavirgen"
            ]
            2 => array:2 [
              "nombre" => "Isabel-Mar&#237;a"
              "apellidos" => "Coronel-P&#233;rez"
            ]
            3 => array:2 [
              "nombre" => "Mar&#237;a-Luisa"
              "apellidos" => "Mart&#237;nez-Barranca"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "pt" => array:9 [
        "pii" => "S2666275223002205"
        "doi" => "10.1016/j.abdp.2023.09.002"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => false
          "ES2" => false
          "LATM" => false
        ]
        "gratuito" => false
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "pt"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666275223002205?idApp=UINPBA00008Z"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059623001903?idApp=UINPBA00008Z"
    "url" => "/03650596/0000009900000001/v1_202401040817/S0365059623001903/v1_202401040817/en/main.assets"
  ]
  "itemAnterior" => array:18 [
    "pii" => "S0365059623001964"
    "issn" => "03650596"
    "doi" => "10.1016/j.abd.2022.04.017"
    "estado" => "S300"
    "fechaPublicacion" => "2024-01-01"
    "aid" => "831"
    "copyright" => "Sociedade Brasileira de Dermatologia"
    "documento" => "simple-article"
    "crossmark" => 1
    "subdocumento" => "crp"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:1 [
      "total" => 0
    ]
    "en" => array:10 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Letter - Clinical</span>"
      "titulo" => "Dermoscopy of pityriasis lichenoides et varioliformis acuta &#40;PLEVA&#41;"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "120"
          "paginaFinal" => "123"
        ]
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:8 [
          "identificador" => "fig0025"
          "etiqueta" => "Figure 5"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr5.jpeg"
              "Alto" => 1675
              "Ancho" => 1675
              "Tamanyo" => 204638
            ]
          ]
          "detalles" => array:1 [
            0 => array:3 [
              "identificador" => "at0025"
              "detalle" => "Figure "
              "rol" => "short"
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Dermoscopy of PLEVA&#46; Atypical target pattern&#46; Red structureless area and subtle white central scale &#40;black arrow&#41; surrounded by a peripheral vascular ring with polymorphous vessels and purplish background &#40;white arrow&#41;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Camilo Arias-Rodriguez, Juan Guillermo Hoyos-Gaviria, Ana Mar&#237;a Mu&#241;oz-Monsalve, Alejandro Hernandez-Martinez"
          "autores" => array:4 [
            0 => array:2 [
              "nombre" => "Camilo"
              "apellidos" => "Arias-Rodriguez"
            ]
            1 => array:2 [
              "nombre" => "Juan Guillermo"
              "apellidos" => "Hoyos-Gaviria"
            ]
            2 => array:2 [
              "nombre" => "Ana Mar&#237;a"
              "apellidos" => "Mu&#241;oz-Monsalve"
            ]
            3 => array:2 [
              "nombre" => "Alejandro"
              "apellidos" => "Hernandez-Martinez"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "pt" => array:9 [
        "pii" => "S2666275223002278"
        "doi" => "10.1016/j.abdp.2023.09.009"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => false
          "ES2" => false
          "LATM" => false
        ]
        "gratuito" => false
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "pt"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666275223002278?idApp=UINPBA00008Z"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059623001964?idApp=UINPBA00008Z"
    "url" => "/03650596/0000009900000001/v1_202401040817/S0365059623001964/v1_202401040817/en/main.assets"
  ]
  "en" => array:17 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Letter - Clinical</span>"
    "titulo" => "Extensive Nicolau syndrome following intramuscular diclofenac sodium injection"
    "tieneTextoCompleto" => true
    "saludo" => "Dear Editor&#44;"
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "123"
        "paginaFinal" => "125"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Rafael Oliveira Amorim, Alana Lu&#237;sa Calixto Carlos da Silva, Camila Arai Seque, Adriana Maria Porro"
        "autores" => array:4 [
          0 => array:4 [
            "nombre" => "Rafael Oliveira"
            "apellidos" => "Amorim"
            "email" => array:1 [
              0 => "amorimdermatologia@gmail.com"
            ]
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:2 [
            "nombre" => "Alana Lu&#237;sa Calixto Carlos da"
            "apellidos" => "Silva"
          ]
          2 => array:2 [
            "nombre" => "Camila Arai"
            "apellidos" => "Seque"
          ]
          3 => array:2 [
            "nombre" => "Adriana Maria"
            "apellidos" => "Porro"
          ]
        ]
        "afiliaciones" => array:1 [
          0 => array:2 [
            "entidad" => "Department of Dermatology&#44; Universidade Federal de S&#227;o Paulo&#44; S&#227;o Paulo&#44; SP&#44; Brazil"
            "identificador" => "aff0005"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:8 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 928
            "Ancho" => 1675
            "Tamanyo" => 224459
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0010"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">After 30 days&#44; in the postoperative period of the first surgical debridement on the left thigh &#40;A&#41; and left leg &#40;B&#41;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Nicolau syndrome &#40;NS&#41;&#44; or embolia cutis medicamentosa&#44; is vascular occlusion with necrosis of the skin and underlying tissues&#44; related to the use of medications such as beta-lactam antimicrobials&#44; non-steroidal anti-inflammatory drugs &#40;NSAIDs&#41; and&#44; more recently&#44; hyaluronic acid fillers&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 66-year-old male patient reported erythema and ecchymosis on the left lower limb&#44; 24&#8239;hours after an intramuscular injection &#40;left gluteus&#41; of diclofenac sodium for abdominal pain&#46; There was rapid progression to tense blisters over the entire limb&#44; with severe pain and edema&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Four days later&#44; the patient came to the emergency room with rectilinear purpuric areas all over the left lower limb&#44; tense blisters with serosanguineous content&#44; and ulcerated areas &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The hypothesis of NS due to intramuscular sodium diclofenac injection was considered&#46; Laboratory investigation for systemic vasculitis with antinuclear antibody &#40;ANA&#41;&#44; anti-DNA&#44; extractable nuclear antigen &#40;ENA&#41;&#44; cryoglobulins and complement was negative&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The lesions worsened &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#44; and the patient was transferred to the Intensive Care Unit and received parenteral antibiotic therapy &#40;vancomycin and meropenem&#41;&#46; After clinical stabilization&#44; surgical debridement sessions were performed &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; with subsequent grafting &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; After three months and four surgical approaches for debridement and grafting&#44; the patient was discharged in good general condition&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">NS was first described in 1924 after an intragluteal injection of bismuth salts for the treatment of syphilis&#46; It occurs after the intramuscular injection of insoluble substances&#44; occurring more frequently with benzathine penicillin and NSAIDs &#40;such as diclofenac&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Diclofenac-induced cases are more common in females&#44; whereas penicillin-induced cases are more common in children&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Theories about its etiopathogenesis involve a combination of factors&#58; stimulation of sympathetic innervation with vasospasm and ischemia&#59; blockade of prostaglandin synthesis by NSAIDs&#44; arterial embolic occlusion by inadvertent intravascular injection&#59; perivascular inflammation due to cytotoxic drug reaction&#59; mechanical injury caused by lipophilic drugs penetrating the vessels&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The clinical picture consists of an erythematous macule with rapid evolution to a livedoid violaceous patch&#46; The onset is usually sudden in relation to the injection but can be delayed&#44; often without injury to the injected site&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The prognosis is unpredictable&#44; with reports of recovery and atrophic scarring at the affected site but also compartment syndrome&#44; hyperkalemia&#44; renal failure&#44; paralysis of the affected limb&#44; and death&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;5</span></a> The diagnosis is clinical&#44; highly suggestive when the lesion starts at the injection site&#44; with distal progression over the injected limb&#46; Histopathology is non-specific and may reveal fatty tissue necrosis and inflammation&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">There is no specific treatment&#44; and analgesia&#44; treatment of secondary infection&#44; and surgical debridement are employed&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The correct intramuscular injection technique can reduce the risk of the condition&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The Z-track injection method is recommended&#44; with traction of the skin and subcutaneous tissue prior to needle insertion&#44; ensuring blockage of the needle path after the injection&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Although rare&#44; NS can be extensive and severe&#46; Physicians must be aware of the condition&#44; as well as aware of the correct injection technique&#44; and avoid unnecessary intramuscular prescriptions&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0055" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#39; contributions</span><p id="par0060" class="elsevierStylePara elsevierViewall">Rafael Oliveira Amorim&#58; Drafting and editing of the manuscript and critical review of important intellectual content&#59; study design together with the co-authors&#59; critical review of the literature&#59; approval of the final version of the manuscript&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Alana Lu&#237;sa Calixto Carlos da Silva&#58; Drafting and editing of the manuscript and critical review of important intellectual content&#59; study design together with the co-authors&#59; approval of the final version of the manuscript&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Camila Arai Seque&#58; Drafting and editing of the manuscript and critical review of important intellectual content&#59; study design together with the co-authors&#59; approval of the final version of the manuscript&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Adriana Maria Porro&#58; Drafting and editing of the manuscript and critical review of important intellectual content&#59; study design together with the co-authors&#59; approval of the final version of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:4 [
        0 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Financial support"
        ]
        1 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Authors&#39; contributions"
        ]
        2 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Conflicts of interest"
        ]
        3 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2022-03-24"
    "fechaAceptado" => "2022-06-03"
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#8902;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Study conducted at the Department of Dermatology&#44; Universidade Federal de S&#227;o Paulo&#44; S&#227;o Paulo&#44; SP&#44; Brazil&#46;</p>"
      ]
    ]
    "multimedia" => array:3 [
      0 => array:8 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1972
            "Ancho" => 1508
            "Tamanyo" => 355917
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0005"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Violaceous&#44; rectilinear lesions with areas of skin detachment on the thigh and leg&#46; Areas of necrosis with an erythematous halo are also observed&#46; &#40;B&#41; Progression of the necrosis areas seven days after symptom onset</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 928
            "Ancho" => 1675
            "Tamanyo" => 224459
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0010"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">After 30 days&#44; in the postoperative period of the first surgical debridement on the left thigh &#40;A&#41; and left leg &#40;B&#41;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1310
            "Ancho" => 1675
            "Tamanyo" => 284027
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0015"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Three months after the onset of the condition&#44; the patient shows good aesthetic and functional recovery in the &#40;A&#41; right thigh and hip and &#40;B&#41; right leg and dorsum of the right foot after multiple skin grafts</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:5 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Nicolau syndrome caused by non-steroidal anti-inflammatory drugs&#58; Systematic literature review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46;F&#46; Lardelli"
                            1 => "L&#46;M&#46;M&#46; Jermini"
                            2 => "G&#46;P&#46; Milani"
                            3 => "G&#46;G&#46;A&#46;M&#46; Peeters"
                            4 => "G&#46;P&#46; Ramelli"
                            5 => "L&#46; Zgraggen"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/ijcp.13567"
                      "Revista" => array:5 [
                        "tituloSerie" => "Int J Clin Pract"
                        "fecha" => "2020"
                        "volumen" => "74"
                        "paginaInicial" => "e13567"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32479658"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Intramuscular diclofenac is a cause of Nicolau syndrome in obese women&#58; An observational study of consecutive ten patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "H&#46; Aktas"
                            1 => "O&#46;E&#46; Y&#305;lmaz"
                            2 => "G&#46; Ertugrul"
                            3 => "E&#46; Terzi"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Dermatol Ther"
                        "fecha" => "2020"
                        "volumen" => "33"
                        "paginaInicial" => "e13392"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Hyperacute paraplegia and neurovascular &#40;immuno vasculotoxic&#41; catastrophe of nicolau syndrome&#58; Primum non nocere"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "B&#46; Shelley"
                            1 => "P&#46; Prasad"
                            2 => "M&#46; Manjunath"
                            3 => "S&#46; Chakraborti"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.4103/aian.AIAN_298_18"
                      "Revista" => array:5 [
                        "tituloSerie" => "Ann Indian Acad Neurol"
                        "fecha" => "2019"
                        "volumen" => "22"
                        "paginaInicial" => "104"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30692770"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Late development of Nicolau syndrome - Case report"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "A&#46;M&#46;M&#46; Silva"
                            1 => "A&#46; Ton"
                            2 => "T&#46;F&#46; Loureiro"
                            3 => "B&#46;L&#46; Agrizzi"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "An Bras Dermatol"
                        "fecha" => "2011"
                        "volumen" => "86"
                        "paginaInicial" => "157"
                        "paginaFinal" => "159"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "An exceptional cause of acute limb ischemia&#58; Nicolau syndrome-single-center experience with 4 cases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "F&#46; Marcus"
                            1 => "E&#46;V&#46; Claude"
                            2 => "M&#46; Josephine"
                            3 => "A&#46; Teyang"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Ann Vasc Surg"
                        "fecha" => "2019"
                        "volumen" => "58"
                        "paginaInicial" => "383"
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/03650596/0000009900000001/v1_202401040817/S0365059623002064/v1_202401040817/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "95153"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Letter - Clinical"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/03650596/0000009900000001/v1_202401040817/S0365059623002064/v1_202401040817/en/main.pdf?idApp=UINPBA00008Z&text.app=https://clinics.elsevier.es/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059623002064?idApp=UINPBA00008Z"
]
Share
Journal Information
Vol. 99. Issue 1.
Pages 123-125 (1 January 2024)
Visits
3908
Vol. 99. Issue 1.
Pages 123-125 (1 January 2024)
Letter - Clinical
Full text access
Extensive Nicolau syndrome following intramuscular diclofenac sodium injection
Visits
3908
Rafael Oliveira Amorim
Corresponding author
amorimdermatologia@gmail.com

Corresponding author.
, Alana Luísa Calixto Carlos da Silva, Camila Arai Seque, Adriana Maria Porro
Department of Dermatology, Universidade Federal de São Paulo, São Paulo, SP, Brazil
This item has received
Article information
Full Text
Bibliography
Download PDF
Statistics
Figures (3)
Show moreShow less
Full Text
Dear Editor,

Nicolau syndrome (NS), or embolia cutis medicamentosa, is vascular occlusion with necrosis of the skin and underlying tissues, related to the use of medications such as beta-lactam antimicrobials, non-steroidal anti-inflammatory drugs (NSAIDs) and, more recently, hyaluronic acid fillers.

A 66-year-old male patient reported erythema and ecchymosis on the left lower limb, 24 hours after an intramuscular injection (left gluteus) of diclofenac sodium for abdominal pain. There was rapid progression to tense blisters over the entire limb, with severe pain and edema.

Four days later, the patient came to the emergency room with rectilinear purpuric areas all over the left lower limb, tense blisters with serosanguineous content, and ulcerated areas (Fig. 1A).

Figure 1.

(A) Violaceous, rectilinear lesions with areas of skin detachment on the thigh and leg. Areas of necrosis with an erythematous halo are also observed. (B) Progression of the necrosis areas seven days after symptom onset

(0.34MB).

The hypothesis of NS due to intramuscular sodium diclofenac injection was considered. Laboratory investigation for systemic vasculitis with antinuclear antibody (ANA), anti-DNA, extractable nuclear antigen (ENA), cryoglobulins and complement was negative.

The lesions worsened (Fig. 1B), and the patient was transferred to the Intensive Care Unit and received parenteral antibiotic therapy (vancomycin and meropenem). After clinical stabilization, surgical debridement sessions were performed (Fig. 2) with subsequent grafting (Fig. 3). After three months and four surgical approaches for debridement and grafting, the patient was discharged in good general condition.

Figure 2.

After 30 days, in the postoperative period of the first surgical debridement on the left thigh (A) and left leg (B)

(0.21MB).
Figure 3.

Three months after the onset of the condition, the patient shows good aesthetic and functional recovery in the (A) right thigh and hip and (B) right leg and dorsum of the right foot after multiple skin grafts

(0.27MB).

NS was first described in 1924 after an intragluteal injection of bismuth salts for the treatment of syphilis. It occurs after the intramuscular injection of insoluble substances, occurring more frequently with benzathine penicillin and NSAIDs (such as diclofenac).1 Diclofenac-induced cases are more common in females, whereas penicillin-induced cases are more common in children.2

Theories about its etiopathogenesis involve a combination of factors: stimulation of sympathetic innervation with vasospasm and ischemia; blockade of prostaglandin synthesis by NSAIDs, arterial embolic occlusion by inadvertent intravascular injection; perivascular inflammation due to cytotoxic drug reaction; mechanical injury caused by lipophilic drugs penetrating the vessels.2,3

The clinical picture consists of an erythematous macule with rapid evolution to a livedoid violaceous patch. The onset is usually sudden in relation to the injection but can be delayed, often without injury to the injected site.4 The prognosis is unpredictable, with reports of recovery and atrophic scarring at the affected site but also compartment syndrome, hyperkalemia, renal failure, paralysis of the affected limb, and death.3,5 The diagnosis is clinical, highly suggestive when the lesion starts at the injection site, with distal progression over the injected limb. Histopathology is non-specific and may reveal fatty tissue necrosis and inflammation.5

There is no specific treatment, and analgesia, treatment of secondary infection, and surgical debridement are employed.1 The correct intramuscular injection technique can reduce the risk of the condition.4 The Z-track injection method is recommended, with traction of the skin and subcutaneous tissue prior to needle insertion, ensuring blockage of the needle path after the injection.1

Although rare, NS can be extensive and severe. Physicians must be aware of the condition, as well as aware of the correct injection technique, and avoid unnecessary intramuscular prescriptions.

Financial support

None declared.

Authors' contributions

Rafael Oliveira Amorim: Drafting and editing of the manuscript and critical review of important intellectual content; study design together with the co-authors; critical review of the literature; approval of the final version of the manuscript.

Alana Luísa Calixto Carlos da Silva: Drafting and editing of the manuscript and critical review of important intellectual content; study design together with the co-authors; approval of the final version of the manuscript.

Camila Arai Seque: Drafting and editing of the manuscript and critical review of important intellectual content; study design together with the co-authors; approval of the final version of the manuscript.

Adriana Maria Porro: Drafting and editing of the manuscript and critical review of important intellectual content; study design together with the co-authors; approval of the final version of the manuscript.

Conflicts of interest

None declared.

References
[1]
P.F. Lardelli, L.M.M. Jermini, G.P. Milani, G.G.A.M. Peeters, G.P. Ramelli, L. Zgraggen, et al.
Nicolau syndrome caused by non-steroidal anti-inflammatory drugs: Systematic literature review.
Int J Clin Pract, 74 (2020), pp. e13567
[2]
H. Aktas, O.E. Yılmaz, G. Ertugrul, E. Terzi.
Intramuscular diclofenac is a cause of Nicolau syndrome in obese women: An observational study of consecutive ten patients.
Dermatol Ther, 33 (2020), pp. e13392
[3]
B. Shelley, P. Prasad, M. Manjunath, S. Chakraborti.
Hyperacute paraplegia and neurovascular (immuno vasculotoxic) catastrophe of nicolau syndrome: Primum non nocere.
Ann Indian Acad Neurol, 22 (2019), pp. 104
[4]
A.M.M. Silva, A. Ton, T.F. Loureiro, B.L. Agrizzi.
Late development of Nicolau syndrome - Case report.
An Bras Dermatol, 86 (2011), pp. 157-159
[5]
F. Marcus, E.V. Claude, M. Josephine, A. Teyang.
An exceptional cause of acute limb ischemia: Nicolau syndrome-single-center experience with 4 cases.
Ann Vasc Surg, 58 (2019), pp. 383

Study conducted at the Department of Dermatology, Universidade Federal de São Paulo, São Paulo, SP, Brazil.

Copyright © 2023. Sociedade Brasileira de Dermatologia
Download PDF
Idiomas
Anais Brasileiros de Dermatologia
Article options
Tools
en pt
Cookies policy Política de cookies
To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here. Utilizamos cookies próprios e de terceiros para melhorar nossos serviços e mostrar publicidade relacionada às suas preferências, analisando seus hábitos de navegação. Se continuar a navegar, consideramos que aceita o seu uso. Você pode alterar a configuração ou obter mais informações aqui.