Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Aug 2018

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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
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Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Case report
Year : 2011 | Month : November | Volume : 5 | Issue : 6 | Page : 1295 - 1297 Full Version

An Unusual Case of Cutaneous Gangrene

Published: November 1, 2011 | DOI:
Mahalingam Soundarya, Kumar Ranjith, Bhat Kamalakshi

M.D Paediatrics, Kasturba Medical College, Mangalore (Affiliated to Manipal University), India. M.D. Paediatrics, Kasturba Medical College, Mangalore, India. M.D.Paediatrics, Kasturba Medical College, Mangalore, India.

Correspondence Address :
Mahalingam Soundarya, Assistant Professor,
Department of Paediatrics, Kasturba Medical College Hospital,
Attavara, Mangalore. Pin 575001


Benzathine penicillin is used intramuscularly for the prophylaxis of rheumatic heart disease. We describe here, a child with cutaneous gangrene following an accidental intra-arterial injection of benzathine penicillin in the gluteal area, which was resolved by symptomatic therapy. This is a dangerous but possible adverse effect of this commonly used drug, which can occur due to the practical difficulties which are faced in ruling out intra-arterial injection with this opaque and viscous preparation.


Benzathine penicillin, Cutaneous gangrene, Intra-arterial injection

Benzathine penicillin is a drug which is commonly used for the secondary prophylaxis of rheumatic fever, which has a high incidence in our country. This drug is being given deep intramuscularly to children for many years and in children with valvular heart disease, a lifelong treatment is required. Hence, this drug is being administered in many smaller hospitals and outreach centres and even by paramedical personnel. We report here, an adverse event of this drug that is rare; so far, only few (3) cases have been reported, mostly in infants; it can occur even when the utmost caution is used in the administration of the drug, but it has near lethal consequences.

Case Report

Case History
A 9 year old boy, who was on secondary prophylaxis with Inj. Benzathine penicillin for rheumatic fever since 7 months, received an intramuscular injection of Benzathine penicillin in the right gluteal region, after being tested for hypersensitivity by using crystalline penicillin. The child was kept under observation for the next half an hour and was then discharged. As the child walked for about 5 minutes, he developed an excruciating pain over the injection site and in both the lower limbs, mainly in the calf muscles, more on the right side. There was no paresthaesia. The right lower limb was pale and cold to touch and the injection site was tender but normal in colour. The child had tachycardia (130/min) and hypertension (170/90 mm of Hg). Peripheral pulses were felt normally in both the lower limbs (Table/Fig 1). The neurological examination of the affected limb revealed hypotonia, areflexia, reduced power (2/5) and flexor plantar response. The other limb also showed similar findings, but with a better tone and power (3/5). The response to any sensory stimulus was inconsistent. An immediate I.V. accesswas secured and one dose of injection hydrocortisone was given. Hot water compresses, I.V. fluids and analgesics were started simultaneously. After about 45 minutes, there was a reduction in the pain and erythematous patches were noticed over the tender oedematous right gluteal region and over the tip of the toes, which became more prominent after 12 hours (Table/Fig 2).

Six hours after the injection, there was a gradual neurological recovery, as was evident through an improved muscle power (4/5), a normal muscle tone, diminished reflexes (1+) and normal sensations over the right lower limb. Also, there was improvement in the temperature of the right lower limb. By 18 hours, there were multiple irregular cutaneous gangrenous patches over the swollen, tender, right gluteal region and the distal 1/3rd of the right foot, along with a restriction of the hip movements and discolourationof the tip of the glans penis (Table/Fig 3). The child was started on I.V. heparin and antibiotics (Piperacillin + Tazobactum, Amikacin). Heparinization was continued for 4 days with regular monitoring of the PT-INR. USG showed oedematous gluteal maximus with no evidence of haematoma or joint effusion. Arterial Doppler was normal in both the lower limbs. At 44 hours, a fasciotomy was done (Table/Fig 4). The blood and tissue cultures were sterile. In view of the hypertension, nifedipine was added, which was continued for 4 days and was then stopped. The blood investigations on day1 showed leucocytosis (16750/cmm) with neutrophilia (87%), a borderline platelet count (1.56 lakh) and elevated liver enzymes (SGPT=396); urea, creatinine and electrolytes were normal. The child was discharged after 8 days once the symptoms improved and he was able to walk with mild pain. At review after 2 weeks, he had an antalgic gait with healed skin lesions over the gluteal region and peeling of the skin over the previous gangrenous patches over the anterior 1/3rd of the foot (Table/Fig 5) and (Table/Fig 6). The child is currently on oral penicillin V prophylaxis and is neurologically normal.


An accidental intra-arterial injection of benzathine penicillin is a possible but hazardous side effect of this drug. Benzathine penicillin and Procaine penicillin, both being opaque and viscous preparations for intramuscular injection, the visualization of the aspirated blood is difficult and hence, there is no absolute possibility of being completely sure of avoiding the intravascular injection of the drug (1). A spectrum of injuries, sometimes permanent, to the gluteal region, the distal extremities, the perineum and the spinal cord, has been documented, which results from the inadvertent intra-arterial injection, probably due to vascular occlusion by the large crystals of the penicillin salts (2). On further analysis of the literature, it was postulated that the patient had received an unintentional injection of Benzathine penicillin into the gluteal artery and that he subsequently developed the ‘Nicolau syndrome’, which has been described as ‘livedoid dermatitis’ – a very rare complication of the intramuscular injections which manifest asexcruciating pain, immediately after the injection, followed by discolouration and oedema (3),(4). As the clinical features of such an accidental intra-arterial injection depend on the vessel into which the penicillin salt had been injected, dangerous and irreversible complications like progressive paralysis and paraplegia which are similar to transverse myelitis, have been described in the literature following the occlusion of the spinal vasculature. The earlier case reports have been documented in infants, wherein even profound complications like coma, convulsions and death have occurred (5).

Our case report reiterates the fact that the complications which are associated with an intramuscular injection of Benzathine penicillin, which have been described in the literature in the earlier decades and now have almost been forgotten, are still very significant. In peripheral health set ups where auxiliary health professionals administer the drug intramuscularly, these adverse events arevery much possible and they could end up in very dangerous and sometimes lethal side effects. Hence, using penicillin preparations with caution, awareness of the occurrence of such complications and their immediate management is the need of the hour.

Key Message

The intra-arterial injection of Benzathine penicillin is a dangerous and possible adverse effect of this commonly used drug, which is used by paramedical workers in outreach centres. Hence, using the penicillin preparations with caution, and the immediate management of the complications if any, is the need of the hour.


Wynne JM, Williams GL, Elliman BA. Accidental intra-arterial injection of Benzathine penicillin. Arch Dis Child 1978; 53: 396-400.
Weir MR. intravascular injuries due to intra-muscular penicillin. Clin Pediatr (Phila) 1988 Feb; 27/ 2: 85-90.
Wroneckik, Czernik J. Nicolau Syndrome. Z Kinderchir 1981 Apr; 32/4: 367-70. PMID 7282075
Ocak S, Ekici B, Cam H, Tastan Y. Nicolau syndrome – a complication of intra-arterial Benzathine penicillin. Paed Infect Dis J. Aug 2006; 25(8): 749. PMID–16874179
Stafford WW, Mena H, Piskun WS, Weir MR. Transverse myelitis due to the intra-arterial administration of penicillin. Neurosurgery 1984 Oct; 15(4):552-6.

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