Nicolau syndrome (NS) is a rare iatrogenic syndrome usually following intramuscular (IM) injection of various described medications. The typical presentation involves immediate injection site pain and development of a livedoid reticular patch, which can progress to muscle necrosis requiring surgical debridement. The pathophysiology is unclear, although vasoconstrictive etiologies have been implicated. Treatment ranges from supportive care to surgical debridement. The authors present a case report of this syndrome as well as a review of the literature and introduction to a new treatment modality. NS in a 52-year-old woman following IM injection of Demerol and Phenergan to address pain and nausea before discharge is reported. This occurred in the post-anesthesia care unit after aesthetic breast surgery in an ambulatory surgery center. Our patient had immediate injection site pain and a hemorrhagic patch was evident on her physical examination the following day. With local care and hyperbaric oxygen therapy, her lesion improved in appearance. However, she continued to have debilitating pain and was referred to a specialist for osteopathic manipulative therapy (OMT), which had the greatest impact on her pain level. After multi-modal therapy was initiated, the syndrome ultimately resolved without the need for surgical debridement. However, she continues to experience pain and ambulates with a limp due to muscle atrophy. NS is a rare diagnosis that can have devastating complications that can be averted by early recognition and initiation of treatment modalities. In this case, the authors introduced OMT as a new treatment modality, with the potential to improve the progression of this syndrome.

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doi.org/10.1093/asjof/ojaa027