An Exceptional Cause of Acute Limb Ischemia: Nicolau Syndrome—Single-Center Experience with 4 Cases

Causes of acute limb ischemia are classically mainly emboli and thrombosis. Nicolau syndrome is a very rare complication of intramuscular injection presumed to be related to the inadvertent intravascular injection. It was first reported after intramuscular injection of bismuth salt, but it can occur as a complication of various other drugs. Acute limb ischemia is one of its severe outcomes but is rarely encountered and reported.Patients admitted with the final diagnosis of Nicolau syndrome in our institution in 3 years (2016 2017 and 2018) are reviewed in terms of etiology, clinical presentation, management, and outcome.We present here 4 cases of Nicolau syndrome that lead to acute limb ischemia and with the same outcome: limb or fingers loss; there were 2 upper extremities for 2 women secondary to diclofenac and dexamethasone intramuscular administration and 2 lower extremities for 2 men in relation with Benzathine Penicillin intramuscular administration. The medical and surgical management that we attempted did not prevent this severe outcome.Nicolau syndrome should be considered when looking for rare etiologies of acute limb ischemias.