# An Unusual Presentation of Nicolau Syndrome in the Upper Limb: A Case Report from Northern Ecuadorian Amazonia

## TL;DR

A 22-year-old transgender woman in Ecuador developed Nicolau syndrome after self-administering an IV drug, highlighting risks of unsafe medication practices and the need for better healthcare training.

## Contribution

This case report presents an unusual upper limb manifestation of Nicolau syndrome in a transgender woman from a low-resource setting.

## Key findings

- The patient developed severe pain, livedoid dermatitis, and distal cyanosis after self-administering benzathine penicillin.
- Medical management led to partial improvement, but persistent ischemic changes raised concerns for potential finger necrosis.
- The case emphasizes the importance of safe injection practices and healthcare worker training in preventing and managing Nicolau syndrome.

## Abstract

Nicolau syndrome, also known as embolia cutis medicamentosa, is a rare iatrogenic reaction that may occur following parenteral drug administration, including inadvertent intra-arterial or periarterial injection. Its pathophysiology remains poorly understood; however, several mechanisms have been proposed, including vasospasm, embolization, cytotoxic inflammation, and secondary tissue necrosis. We report the case of a 22-year-old transgender woman who received intravenous benzathine penicillin in the left arm without a medical prescription following a reactive syphilis screening performed outside a formal healthcare setting. She subsequently developed severe pain, livedoid dermatitis, pallor, distal cyanosis, and blister formation. Radial and brachial pulses remained palpable, and Doppler ultrasonography revealed no evidence of arterial or venous thrombosis. Medical management included daily wound care, anticoagulation, corticosteroids, peripheral vasodilators, antibiotic therapy, and analgesia. The patient was hospitalized for nine days, with partial clinical improvement. However, persistent distal ischemic changes involving the second through fifth fingers raised concern for evolving necrosis and potential amputation. After counseling regarding these risks, the patient requested voluntary discharge. This case underscores the importance of safe medication administration and appropriate injection practices, particularly in low-resource settings. It also highlights the need for improved training of healthcare personnel to ensure early recognition and prompt management of Nicolau syndrome, as well as strengthened patient education to discourage self-medication and promote timely care by qualified healthcare professionals.