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Journal of Indian Association of Pediatric Surgeons
     Journal of Indian Association of Pediatric Surgeons
Official journal of the Indian Association of Pediatric Surgeons         
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LETTERS TO THE EDITOR
Year : 2023  |  Volume : 28  |  Issue : 6  |  Page : 551-552
 

Nicolau syndrome: Disastrous consequence of injection sclerotherapy


Department of Paediatric Urology and Paediatric Surgery, Apollo Institute of Paediatric Sciences, Indraprastha Apollo Hospitals, New Delhi, India

Date of Submission14-Aug-2023
Date of Decision24-Sep-2023
Date of Acceptance28-Sep-2023
Date of Web Publication02-Nov-2023

Correspondence Address:
Sujit K Chowdhary
Department of Paediatric Urology and Paediatric Surgery, Apollo Institute of Paediatric Sciences, Indraprastha Apollo Hospitals, New Delhi - 110 076
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaps.jiaps_171_23

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How to cite this article:
Nair N, Baruah AJ, Pannu A, Chowdhary SK. Nicolau syndrome: Disastrous consequence of injection sclerotherapy. J Indian Assoc Pediatr Surg 2023;28:551-2

How to cite this URL:
Nair N, Baruah AJ, Pannu A, Chowdhary SK. Nicolau syndrome: Disastrous consequence of injection sclerotherapy. J Indian Assoc Pediatr Surg [serial online] 2023 [cited 2023 Nov 28];28:551-2. Available from: https://www.jiaps.com/text.asp?2023/28/6/551/389322




Sir,

Soft-tissue lumps are frequently encountered surgical lesions in children. The most common lesions are developmental hamartomas which may have a vascular or lymphangiomatous component. We report a case of acute limb ischemia following intralesional sclerotherapy with sodium tetradecyl sulfate for a soft-tissue swelling of the forearm. This is the second reported case of limb ischemia following sodium tetradecyl sulfate (STS) injection in India.[1],[2]

A 5-year-old boy presented to a district hospital with a 2 cm × 2 cm swelling on the dorsal aspect of the right forearm, where he underwent injection sclerotherapy. He reached us on the fourth day after injection sclerotherapy with bluish discoloration of the entire right forearm and loss of movement in the fingers and wrist joint [Figure 1]. An ultrasound Doppler revealed absent flow in radial, ulnar, and brachial arteries. The axillary artery was pulsatile with a normal flow pattern. Vascular surgery, plastic surgery, and orthopedic teams were consulted and advised above-elbow amputation. In view of delay and absent flow in Doppler ultrasound, computed tomography angiography was not considered. The situation was explained to the family and above-elbow amputation was performed. The amputation stump healed well, and he was discharged within a week with physical rehabilitation and prosthesis management over the next few months.
Figure 1: Day 4 postinjection sclerotherapy

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This complication is similar in its etiopathogenesis to Nicolau syndrome, first described in 1925, as iatrogenic necrosis of skin and underlying tissue after intramuscular bismuth injection in syphilis patients. The mechanisms responsible include direct arterial embolization of the vessel, periarterial ischemia due to arterial vasospasm and compression of the vessel by the injected material. Conservative management with anticoagulants and antibiotics has been known to help in patients with early signs of decreased perfusion, in the first 6–12 h.[2]

This case is being reported to highlight the rare but devastating potential complication of injection sclerotherapy with STS in a child.

We recommend close monitoring of the injection site up to 6 h post sclerotherapy, within which any ischemic changes may be reversed, and the limb salvaged.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Deshmukh NS, Abhijit Belgaumkar V, Chavan RB, Bhatt N. Nicolau syndrome following intralesional sclerotherapy: A dreaded complication of a simple office procedure. J Skin Stem Cell 2020;7:107198.  Back to cited text no. 1
    
2.
Nischal K, Basavaraj H, Swaroop M, Agrawal D, Sathyanarayana B, Umashankar N. Nicolau syndrome: An iatrogenic cutaneous necrosis. J Cutan Aesthet Surg 2009;2:92-5.  Back to cited text no. 2
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