Successful Limb Salvage in Pediatric Nicolau Syndrome Following Intramuscular Benzathine Penicillin: A Case Report

Abstract

Nicolau syndrome, also known as emboli cutis medicamentosa, is a rare but potentially severe complication of parenteral drug administration that may lead to acute pain, livedoid discoloration, and cutaneous or subcutaneous necrosis. We report the case of a 4-year-old boy who developed Nicolau syndrome shortly after intramuscular administration of benzathine penicillin for streptococcal pharyngitis. He presented with sudden severe pain, pallor, mottling, and livedoid changes involving the injected limb and adjacent regions. Prompt recognition and multidisciplinary conservative management, including anticoagulation, topical vasodilator therapy, corticosteroids, limb elevation, and intensive monitoring, were associated with progressive clinical
improvement and preservation of limb function. This case highlights the importance of early diagnosis and timely supportive intervention in preventing severe ischemic complications of Nicolau syndrome.