TITLE:
A Rare Case of Nicolau Syndrome Secondary to Intramuscular Injection of Benzathine Benzylpenicillin
AUTHORS:
Ndiaga Diakhaté, Lamine Thiam, Khadim Diop, Maguette Aicha Ndiaye, Cheikh Tijane Mbaye, Isabelle Jocké Coly, Christ Tsague Momo, Ndeye Rama Diagne, Papa Moctar Faye, Amadou Lamine Fall, Ousmane Ndiaye
KEYWORDS:
Infant, Nicolau Syndrome, Benzathine Penicillin, Ziguinchor
JOURNAL NAME:
Open Journal of Pediatrics,
Vol.16 No.2,
March
17,
2026
ABSTRACT: Introduction: Nicolau syndrome is a rare iatrogenic syndrome caused by an intramuscular injection of medication, leading to ischemia and then tissue necrosis in a limb, with a prognosis that is mainly functional due to the risk of amputation of the affected limb. We describe a new case in a 24-month-old infant following an IM injection of benzathine penicillin. Patient and Observation: The patient was a 24-month-old male infant with no previous history, who was admitted for sudden functional impotence of a limb. During questioning, the parents reported a visit to a health facility on the outskirts of town for an undocumented dermatosis, which led to an IM injection of benzathine penicillin in the upper third of the right thigh. A few hours later, he presented with pain, incessant crying and, as noted by his parents, functional impotence of the limb. This prompted a second consultation at the same site two days later, where treatment with paracetamol and oral antibiotics was prescribed. When there was no improvement, he was referred to our facility six days later, where he presented with fever, tachycardia and poor general condition. The examination revealed coldness throughout the right lower limb, which was stiff, cyanotic and necrotic in places from the upper third of the thigh to the toes. The pedal and popliteal pulses were absent on palpation. The rest of the clinical examination was normal. The angiography showed total thrombosis of the superficial and deep right femoral arteries extending to the pedal artery. Biological tests revealed hyperleukocytosis at 19,170 and CRP at 102 mg/l. Renal function and blood count were normal. In the absence of other causes of thromboembolic disease, a diagnosis of Nicolau syndrome secondary to an intramuscular injection of benzathine benzylpenicillin was made. Surgical management with transfemoral amputation was performed. The outcome was favorable with healing of the stump. Conclusion: In addition to its rarity, delayed diagnosis is exacerbated by difficulties in accessing specialist care in rural areas. This case calls for greater vigilance in prescribing benzathine benzylpenicillin, which is often misused for certain skin conditions in our African context.