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Compartment syndrome and acute lower limb ischemia with paralysis complicating intramuscular benzathine penicillin injection

Nicolau dermatitis (ND) is a well-known but rare adverse drug reaction involving the skin and the subcutaneous and even muscle tissues at the site of intramuscular injection (IMI). Benzathine penicillin (BP) is the most frequent medication causing serious and acute complications such as limb ischemia, compartment syndrome (CS), and nerve paralysis. The subsequent damage to the lower limb (LL) might be due to microemboli, leading to progressive deterioration of the downstream tissue bed. We describe a 7-year-old boy with a diagnosis of ND after IMI of BP and diclofenac sodium to the medial mid-right thigh. Two days earlier, the patient seemed to experience an acute suppurative complication of circumcision and underwent the aforementioned treatment (September 15, 2018). The circumcision and injection of drugs were illicitly carried out by a nonmedical practitioner. The child complained of severe pain and disability of his right LL. On admission (September 16, 2018), he was found to have acute LL ischemia and CS with cyanosis, hypoesthesia and paresis. Fasciotomy was achieved and medical therapy with heparin, corticoid, and an antibiotic was made for 7 days. Postoperative periods were uneventful. Livedoid violaceous patch and erythematous plaque and ecchymosis have evolved progressively during 10th day, with formation of a diffuse necrotic spot before healing up within 2 months. The length of hospital stay was 10 days. The rehabilitation for walking was started 2 weeks after the operation. Between 6 and 12 months of follow-up, the motor deficit involved the entire LL and persisted despite the tremendous achievement of regular neuromuscular physiotherapy. The paralysis was considered permanent.