The embolia cutis medicamentosa is a rare but serious complication that can be observed as a rule following an intramuscular injection. The disease is associated with localized, sometimes extensive skin necrosis, the treatment of which is tedious.
What is the Embolia cutis medicamentosa?
According to GRADINMATH.COM, Embolia cutis medicamentosa (also Nicolau syndrome, livedo-like dermatitis) is a serious complication as a result of an intramuscular (mostly intragluteal or in the buttocks), in rare cases also intra-articular (applied into the joint cavity) or subcutaneous injection, which in many cases is associated with partially extensive skin necrosis (non-vital skin tissue).
An embolia cutis medicamentosa initially manifests itself within minutes to a few hours after the intramuscular injection on the basis of very hard and painful infiltrations with reddish-livid skin markings as a result of the slowed blood flow and reflex vascular spasms (spasmodic constrictions).
After about 24 to 72 hours, vascular ischemia (insufficient supply), hemorrhagic necrosis and, in the further course, deeper ulcerations can develop. Finally, in an embolia cutis medicamentosa, not only the skin and muscles but also the organs of the small pelvis (pelvis minor) can be affected by necrotic processes.
An embolia cutis medicamentosa usually occurs after an accidental intra- or periarterial injection of intramuscular drugs (especially crystal suspensions).
The exact etiology has not yet been fully clarified. However, it is assumed that the intra- or periarterial injection causes vascular occlusion (vascular blockage) with subsequent ischemia (insufficient supply of blood). The long-term shortage of supply leads to fibrinoid necrosis of the arterioles (small arteries) and capillaries, which also destroy the collagen structure in the affected areas. Thrombosis can also be detected in the terminal vascular system (end flow path).
In particular, intramuscular injections into the gluteal region with depot penicillins are associated with an embolia cutis medicamentosa. In addition, injections with heavy metal salts (including mercury, bismuth), other antibiotics (including sulfonamides, tetracyclines), antisteroidal and phenylbutazone-containing anti-inflammatory drugs (including butazolidine) as well as glucocorticoids, glatiramer acetate (immunomodulator for the therapy of the relapsing coumarin-like embryo) and cutaneous sclerosis. Cases of embolia cutis medicamentosa following vascular sclerosing (including with Polidocanol) have also been observed.
Symptoms, ailments & signs
Embolia cutis medicamentosa is a very serious complication which, in the worst case, can lead to the death of the person affected. For this reason, the disease must be treated immediately to prevent further symptoms. An embolism occurs in the affected blood vessels. Similarly, one can Sclerosis form that affects very negatively on the daily lives of those affected.
There are severe disorders of the blood circulation, so that most patients also suffer from dizziness and blood pressure problems as a result of the Embolia cutis medicamentosa. The heart is also permanently damaged by the disease, which can lead to a heart attack or sudden cardiac death. Furthermore, the embolia cutis medicamentosa leads to changes on the skin, which can lead to significantly reduced aesthetics for the patient.
Scars and wounds appear, which in some cases can be permanent. These skin changes are often associated with psychological complaints or depression, as those affected suffer from a reduced self-esteem or from inferiority complexes. The treatment of Embolia cutis medicamentosa often takes place over a very long period of time, so that those affected are dependent on lengthy treatment.
Diagnosis & course
An embolia cutis medicamentosa is diagnosed on the basis of the anamnesis (including checking whether an intramuscular injection had been made beforehand) and the characteristic symptoms.
In the differential diagnosis, an embolia cutis medicamentosa should be differentiated from other arterial circulation disorders such as an embolism from the left heart valve or the left atrium as well as from a Hoigné syndrome (intravenous embolization), injection abscess and a livedo racemosa due to the livedo-like changes in the skin. The course of an Embolia cutis medicamentosa is usually protracted.
In most cases, with early diagnosis and therapy, the skin changes largely regress and the affected skin area heals after the demarcation of the necrotic areas with flat and atrophic scarring.
Serious complications can occur with Embolia cutis medicamentosa, and the disease must be treated over a relatively long period of time. In most cases, patients have severe embolism and sclerosis. The skin is also affected by ischemia, so that there are considerable restrictions in everyday life for the patient.
The heart is also relatively badly affected by the embolism, which can lead to dangerous complaints. A diagnosis of Embolia cutis medicamentosa is easy so that treatment can begin early. Medicines are used for all types of treatment if the necrosis is not deep and can be treated with them. In a severe form, surgical interventions are necessary to remove these areas.
The wounds must also be cleaned after the treatment so that there are no infections or inflammations. In most cases, the patients experience severe pain. These are treated with the help of painkillers and antibiotics. Although treatment is long-term, it is usually without complications if 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, an immediate doctor’s visit is advisable. Medical advice is required at the latest when the symptoms persist for several days and lead to a decrease in well-being. In the case of circulatory problems and palpitations, it is best to contact the medical emergency service or to take the person affected to the nearest hospital.
Abscesses, open wounds, and infections should be checked for before further complications develop. Embolia cutis medicamentosa occurs mainly after injections, but it can also be triggered by the administration of medication for the treatment of multiple sclerosis. The embolism can also occur following vascular sclerosis.
Anyone who experiences the symptoms mentioned after one of these treatments should speak to the responsible doctor. After the medical examination, a specialist should be consulted for the respective symptoms. Neurologists and specialists in ischemic diseases are particularly useful.
Treatment & Therapy
As part of an external therapy, topical glucocorticoids (e.g. triamcinolone cream) can initially be applied to the affected skin areas in the case of an embolia cutis medicamentosa. If the disease is accompanied by necrosis of the affected skin tissue, wound treatment should be appropriate to the stage.
Following the demarcation (separation of healthy from necrotic tissue) in the case of pronounced and deeper necrosis, the indication for surgical removal (debridement) must be made, as the organism is not able to independently shed the non-vital tissue areas.
In addition, wound cleansing, necrolytic and granulation-promoting measures are used to treat the defective tissue areas. In addition, internal or systemic therapy with non-steroidal and anti-inflammatory (anti-inflammatory) agents (including ibuprofen) is recommended.
In addition, a therapy attempt with vasodilator and blood circulation-enhancing agents (including pentoxifylline, nicotinic acid, papaverine derivatives) may be indicated. In addition, paracetamol or tramadol can be administered to reduce pain. In some cases, prophylactic, systemic therapy with antibiotics such as ofloxacin is indicated, which may be adapted to the results of the antibiogram (determination of antibiotic resistance).
Outlook & forecast
In most cases, those affected by Embolia cutis medicamentosa are dependent on lengthy therapy. Complete healing cannot always be achieved. In some cases, the life expectancy of the patient is also reduced and restricted by the embolia cutis medicamentosa.
Those affected usually need several surgical interventions to alleviate the symptoms. Without treatment, self-healing does not occur and the symptoms often worsen further. The symptoms of Embolia cutis medicamentosa can also be relieved with the help of medication.
It is not uncommon for the disease to lead to psychological upset or depression in the patient, whereby 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 disease is usually not possible.
Exercise caution when injecting a muscle so as not to injure the person concerned. In most cases, an early diagnosis has a very positive effect on the course of the disease and can prevent a protracted course.
An embolia cutis medicamentosa can be avoided with an appropriate approach to intramuscular injections. For example, in order to reduce the risk of embolia cutis medicamentosa, an aspiration (suction attempt) can be carried out for all intramuscular before the application of the solution to be injected, which can be used to check whether a vessel has been punctured by the puncture. In addition, the injection should be carried out under the lowest possible pressure.
In most cases, there are no measures or options for follow-up care available to those affected by Embolia cutis medicamentosa. Since this is a serious complication, it must always be treated immediately by a doctor. This is the only way to prevent further complaints, complications or even the death of the person concerned.
In the case of Embolia cutis medicamentosa, the focus is therefore on early diagnosis and rapid treatment of the disease. It cannot heal on its own, so that the patient is always dependent on medical treatment by a doctor. The treatment itself usually takes the form of a surgical procedure.
This should take place very early 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 consulting a doctor.
If anything is unclear or in doubt, a doctor should always be consulted. When taking antibiotics, care should also be taken to ensure that they should not be taken with alcohol. If the embolia cutis medicamentosa is treated promptly and successfully, there is usually no reduction in the life expectancy of the person affected.
You can do that yourself
Since the embolia cutis medicamentosa can lead to a premature death of the affected person if the outcome is unfavorable, a doctor should be consulted if there are any abnormalities or changes. It is a complication created by a medical procedure. Therefore, there is already contact with a doctor.
Self-help measures are limited in these acute cases, since medical care is necessary for the patient’s survival with Embolia cutis medicamentosa.
The doctor’s instructions should be followed in order to avoid further disturbances or complications. Changes in the state of health should be discussed closely with the attending physician. Independent changes to the treatment plan are not recommended. The observations are to be discussed with a doctor by the person concerned or their relatives. A good relationship of trust with the doctor is helpful. In the event of doubts or uncertainties in working with the doctor, it must be checked whether a second opinion should be obtained.
Extensive information about the disease and its appearance is helpful. Questions should be answered by the attending physician so that misconduct or surprises are avoided. If the person concerned does not feel adequately cared for or informed, this must be addressed openly or alternatives must be sought. This alleviates helplessness and reduces existing fears.