Nicolau syndrome after intramuscular benzathine penicillin injection

Background: Nicolau syndrome is a rare, potentially severe complication that may occur after any drug injection, particularly after intramuscular, subcutaneous or intraarticular injection. The pathogenesis of the necrosis is not completely known, it's presumed that ischemic necrosis is induced by direct vascular injury, perivascular inflammation, and vascular constriction. Few case was reported since the first description by Freudenthal in 1924 and Nicolau in 1925. Case report: we report two cases of Nicolau syndrome in the child after benzathine penicillin intramuscular injection in the thigh. The cases were complicated by a necrosis of the extremities and a Volkmann syndrome. Conclusion: Nicolau syndrome is an uncommon iatrogenic ischemic necrosis of the skin and deeper tissue. It is reported to occur after intramuscular injection for certain drugs such as benzathine penicillin. The pathogenesis is unknown but embolic occlusion, inflammatory and physical obstruction of blood vessels have been suggested in our cases. There is no standard guideline for its management.