Rafael Borrego-Borrego

Descending necrotizing mediastinitis below the tracheal carina

Background Descending necrotizing mediastinitis is a dreadful disease with a high mortality rate, particularly when below the tracheal carina. This study describes the epidemiologic, clinical, and paraclinical features of patients treated for this condition. Methods We performed a single-center retrospective descriptive review of 60 patients with descending necrotizing mediastinitis below the tracheal carina, who were treated during a 7-year period, the largest study in the last 50 years. Demographic, clinical, paraclinical, and therapeutic variables were analyzed. Results 43 (71.7%) patients were male. The mean age was 41.2 ± 14.7 years. Mean hospital length of stay was 25.0 ± 19.8 days. Comorbidities were present in 46.7% of patients, diabetes mellitus being the most common. Odontogenic infections (45%) were the most frequent source of descending necrotizing mediastinitis. Cultures showed Gram-negative bacilli in 68.3%, Gram-positive cocci in 38.3%, and fungi in 6.7%. Mortality was 35% (21 patients); risk factors for mortality were age (>35 years), diabetes mellitus among other comorbidities, and associated complications. Conclusions In this low socioeconomic status patient population, descending necrotizing mediastinitis below the carina causes high morbidity and mortality, the latter particularly associated with age, complications, diabetes mellitus and other comorbidities.

Descending necrotizing mediastinitis associated with spinal cord abscess

A 58-year-old man with a history of Ludwig’s angina was admitted with a spinal cord abscess at the level of C2-T1 and associated osteomyelitic destruction of vertebral bodies, spinal cord compression, and secondary quadriparesis, followed by descending mediastinitis. A right posterolateral thoracotomy and a cervicotomy drained purulent exudates. A tracheostomy was performed, and the patient was discharged after 84 days.

Descending necrotizing mediastinitis and thoracic cellulitis due to varicella

A 22-year-old man with varicella had associated cervical enlargement, right upper thoracic anterior and suprascapular cellulitis, and mediastinitis. A tracheostomy, right posterolateral thoracotomy, cervicotomy, and upper thoracic fasciotomy were performed 14 h after admission, draining purulent exudates from all sites. The patient was discharged on postoperative day 22.

Thoracic necrotizing fasciitis due to snake ointment that progressed to a mediastinitis

We report the case of a 42-year old diabetic male presenting with erythema of the neck and anterior right thoracic region secondary to the application of an ointment derived from rattlesnakes, progressing to a full-blown necrotizing fasciitis in a short period of time, with associated mediastinitis, thrombocytopaenia and sepsis. The patient died despite aggressive multidisciplinary medical and surgical treatment. We present this case due to the unusual aetiology and fulminating course.

Aspergilloma in a pneumonectomized cavity.

A 59-year-old man with a history of left pneumonectomy due to congenital bullae nine years earlier, presented to our institution with cough of five months’ duration, associated with a purulent discharge. Bronchial stump syndrome was diagnosed by bronchoscopy when a communication between the left main bronchus and the ipsilateral thoracic cavity containing purulent material and a grey mass suggestive of an aspergilloma were seen. Computed tomography (Figure 1A and B) and microbiological studies confirmed the disease, with associated contralateral pneumonia probably secondary to aspiration. He was treated with intravenous amphotericin B without success. One month later, a left thoracotomy was performed to resect the capsuled fungus ball which weighted 150 g and had a thickness of 2 cm (Figure 1C), followed by a window thoracostomy for continuous open wound care. The patient is being followed up in the Outpatient Clinic without complications and with a reduction of the window area, as expected.

Descending necrotizing mediastinitis and sternoclavicular joint osteomyelitis

Descending necrotizing mediastinitis is usually associated with cervical or odontogenic infections. We describe a patient with blunt trauma to the chest 2 years earlier, and a slowly developing chest wall hematoma 18 months prior to admission, complicated by chronic sternoclavicular joint osteomyelitis, eventually leading to descending mediastinitis. Thoracotomy with drainage of the mediastinal spaces and multiple procedures for the sternoclavicular joint infection were successful. The rarity of this association and undefined optimal management prompted this report.