Nicolau syndrome appearing approximately one-year post bicillin injection treated with excision


  • Mary K. Dick Creighton School of Medicine, Omaha, Nebraska, USA
  • Robert A. Elmore Department of Pathology, CHI Health Creighton University Medical Center, Omaha, Nebraska, USA
  • Poonam K. Sharma Department of Pathology, CHI Health Creighton University Medical Center, Omaha, Nebraska, USA



Nicolau syndrome, Injection reaction, Fat necrosis


Nicolau syndrome (livedoid dermatitis, embolia cutis medicamentosa) is a unique and painful reaction post intramuscular injection that often ends with necessary necrotic debridement and scarring. We present a case of a 25-year-old female who developed a tender golf ball size lesion with fat necrosis, confirmed by pathology, approximately one year after a Bicillin injection in the buttock. Excision of the mass was necessary for symptomatic relief. To our knowledge, there has never been a report entailing a slow development of Nicolau syndrome over an extended period of time. The pathophysiology of this condition has been attributed to a myriad of causes such as vascular trauma, drug embolism, inflammation, or inappropriate needle length. This syndrome often progresses through three generalized stages before ending in a necrotizing plaque. While there is no current standardized treatment to Nicolau syndrome there are methods for prevention making this important information across the medical field.


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