Embolia cutis medicamentosa is a rare but serious complication that is generally seen following intramuscular injection. The condition is associated with localized skin necrosis, sometimes over large areas, and therapy is lengthy.
What is embolia cutis medicamentosa?
Embolia cutis medicamentosa (also Nicolau syndrome, livedo dermatitis) is a serious complication resulting from an intramuscular (mostly intragluteal or into the buttocks), or in rare cases intraarticular (applied into the joint cavity) or subcutaneous injection, which in many cases is associated with partial extensive skin necrosis (nonvital skin tissue). Embolia cutis medicamentosa initially manifests within minutes to several hours after intramuscular injection by very hard and painful infiltrations with reddish-livid skin markings due to slowed blood flow and reflex vasospasm (spasmodic constriction). After about 24 to 72 hours, vascular ischemia (reduced blood supply), hemorrhagic necrosis, and, in the further course, deeper ulcerations may also develop. Finally, in embolia cutis medicamentosa, necrotization processes may affect the organs of the lesser pelvis (pelvis minor) in addition to the skin and muscles.
Causes
Embolia cutis medicamentosa usually occurs after accidental intra- or periarterial injection of drugs to be applied intramuscularly (especially crystal suspensions). The exact etiology has not yet been fully elucidated. However, it is assumed that the intra- or periarterial injection causes vascular occlusion (vascular blockage) with subsequent ischemia (reduced blood supply). Due to the long-term reduced blood supply, fibrinoid necrosis of the arterioles (small arteries) and capillaries occurs, which also destroys the collagen structure in the affected areas. Thrombosis in the terminal vascular system (end-stream pathway) can also be observed. In particular, intramuscular injections into the gluteal region with depot penicillins are associated with embolia cutis medicamentosa. In addition, injections with heavy metal salts (including mercury, bismuth), other antibiotics (including sulfonamides, tetracyclines), antisteroidal and phenylbutazone-containing antirheumatic drugs (including butazolidine), as well as glucocorticoids, glatiramer acetate (immunomodulator for the therapy of relapsing-remitting multiple sclerosis), and coumarins may cause embolia cutis medicamentosa. Similarly, cases of embolia cutis medicamentosa are observed following vascular sclerotherapy (including polidocanol).
Symptoms, complaints, and signs
Embolia cutis medicamentosa is a very serious complication that, in the worst case, can lead to the death of the affected person. For this reason, the disease must be treated immediately to prevent further symptoms. In this case, an embolism occurs at the affected blood vessels. Likewise, sclerosis can develop, which has a very negative effect on the daily life of the affected person. Strong disturbances of the blood circulation occur, so that most patients also suffer from dizziness and from blood pressure complaints due to embolia cutis medicamentosa. The heart is also permanently damaged by the disease, so that a heart attack or sudden cardiac death can occur. Furthermore, embolia cutis medicamentosa leads to changes on the skin, which can result in significantly reduced aesthetics of the patient. Scars and wounds occur, which in some cases may remain permanently. These skin changes are also often associated with psychological discomfort or depression, as the affected individuals suffer from decreased self-esteem or inferiority complexes. Treatment of embolia cutis medicamentosa often takes place over a very long period of time, leaving sufferers to rely on prolonged treatment.
Diagnosis and course
Embolia cutis medicamentosa is diagnosed on the basis of the patient’s history (including checking whether there had been a previous intramuscular injection) and characteristic symptoms.The differential diagnosis of cutaneous embolism should be differentiated from other arterial circulatory disorders such as embolism from the left heart valve or left atrium, Hoigné syndrome (intravenous embolization), syringe abscess, and livedo racemosa because of the livedo-like changes in the skin. The course of an embolia cutis medicamentosa is usually protracted. In most cases, the skin lesions largely regress with early diagnosis and therapy, and the affected skin area heals with shallow as well as atrophic scarring after demarcation of the necrotic areas.
Complications
Serious complications can occur in embolia cutis medicamentosa, and the disease must be treated over a relatively long period of time. In most cases, patients suffer from severe embolism and sclerosis. The skin is also affected by ischemia, resulting in significant limitations for the patient in everyday life. The heart is also relatively severely affected by the emboli, so that dangerous symptoms can occur in this case. A diagnosis of embolia cutis medicamentosa is easily possible, so that treatment can begin early. In the treatment, mainly medications are used if the necrosis is not deep and can be treated with them. In case of a severe form, surgical interventions are necessary to remove these areas. Likewise, the wounds must be cleaned after treatment to prevent infection or inflammation. In most cases, patients suffer from severe pain. These are treated with the help of painkillers and antibiotics. Although the treatment takes place over a long period of time, it is usually without complications if it is started early.
When should you go to the doctor?
If skin changes, muscle pain, and other signs of embolia cutis medicamentosa occur after an injection, immediate medical attention is advised. At the latest, if the symptoms persist for several days and lead to a decrease in well-being in the course of time, medical advice is required. In the event of circulatory problems and palpitations, it is best to contact the emergency medical service or take the affected person to the nearest hospital. Abscesses, open wounds and infections should be clarified before further complications occur. Embolia cutis medicamentosa occurs predominantly after injections, although it can also be triggered by the administration of drugs used to treat multiple sclerosis. Likewise, embolism can occur following vascular sclerotherapy. Anyone who experiences symptoms mentioned after one of these treatments should talk to the doctor in charge. Following the medical clarification, a specialist should be consulted for the respective symptoms. Neurologists and specialists in ischemic diseases are particularly useful.
Treatment and therapy
As part of external therapy, topical glucocorticoids (eg, triamcinolone cream) may initially be applied to the affected skin areas in cases of embolia cutis medicamentosa. If the disease is accompanied by necrotization of the affected skin tissue, wound treatment appropriate to the stage should be given. Following demarcation (demarcation of healthy from necrotic tissue), surgical ablation (debridement) may be indicated in the case of pronounced and deep necrosis, since the organism is unable to reject the non-vital tissue areas on its own. Furthermore, wound cleansing, necrolytic as well as granulation-promoting measures are used to treat the defective tissue areas. In addition, internal or systemic therapy with nonsteroidal and antiphlogistic (anti-inflammatory) agents (including ibuprofen) is recommended. Furthermore, therapy with vasodilators and agents that promote blood flow (including pentoxifylline, nicotinic acid, papaverine derivatives) may be indicated. In addition, paracetamol or tramadol can be applied to reduce pain. In some cases, prophylactic systemic therapy with antibiotics such as ofloxacin is indicated, adapted as appropriate to the results of the antibiogram (antibiotic resistance determination).
Outlook and prognosis
In most cases, those affected with embolia cutis medicamentosa are dependent on prolonged therapy. Complete cure cannot always be achieved.In some cases, the patient’s life expectancy is also reduced and limited by embolia cutis medicamentosa. Sufferers are usually dependent on several surgical interventions to alleviate the symptoms. Without treatment, this does not result in self-healing and often leads to further worsening of symptoms. The symptoms of embolia cutis medicamentosa can also be alleviated with the help of medication. Not infrequently, the disease can also lead to psychological upsets or depression in the patient, and relatives and friends and these complaints can also suffer. In such cases, those affected are dependent on a visit to a psychologist. Direct prevention of this condition is usually not possible. In the case of a muscular injection, increased caution is required so as not to injure the affected person. In most cases, early diagnosis has a very positive effect on the course of the disease and can prevent a protracted course.
Prevention
Embolia cutis medicamentosa can be prevented by a proper approach to intramuscular injections. For example, to reduce the risk of embolia cutis medicamentosa in all intramuscular injections, an aspiration (suction test) can be performed before application of the solution to be injected, which can be used to check whether a vessel has been punctured by the injection. In addition, the injection should be performed under as little pressure as possible.
Follow-up
Measures or options for aftercare are not available to the affected person in most cases of embolia cutis medicamentosa. Because this is a serious complication, it must always be treated immediately by a physician. This is the only way to prevent further complaints, complications or even death of the affected person. In the case of embolism cutis medicamentosa, the focus is therefore on early diagnosis with rapid treatment of the disease. It cannot heal on its own, so the patient is always dependent on medical treatment by a doctor. The treatment itself is usually carried out by means of a surgical intervention. This should take place at a very early stage so that the infections cannot continue to spread. In many cases, those affected by embolia cutis medicamentosa are dependent on taking medication. These should also be taken after consultation with a physician. In case of uncertainty or doubt, a physician should always be consulted. When taking antibiotics, it should also be noted that they should not be taken together with alcohol. If embolia cutis medicamentosa is treated timely and successfully, there is usually no reduced life expectancy of the affected person.
What you can do yourself
Because embolia cutis medicamentosa can lead to premature death of the affected person if it progresses unfavorably, a physician should be consulted if abnormalities or changes occur. It is a complication, which were made by a medical intervention. Therefore, there is already contact with a doctor. Self-help measures are limited in these acute cases, since in embolia cutis medicamentosa medical care is necessary for the survival of the patient. The physician’s instructions should be followed to avoid further disorders or complications. Changes in the patient’s health condition should be discussed closely with the attending physician. Independent changes in the treatment plan are not recommended. Observations should be discussed by the patient or his relatives with a physician. A good relationship of trust with the physician is helpful. If there are doubts or uncertainties in the cooperation with the physician, it must be checked whether a second opinion should be obtained. A comprehensive explanation of the disease and its appearance is helpful. Questions should be answered by the attending physician so that malpractice or surprises can be avoided. If the affected person does not feel sufficiently cared for or informed, this should be addressed openly or alternatives must be sought. This alleviates helplessness and reduces existing fears.
