Walid Leonardo Dajer-Fadel

Systematic review of spontaneous pneumomediastinum: a survey of 22 years' data.

Objective To describe and clarify management protocols in relation to spontaneous pneumomediastinum, and try to integrate criteria on this subject. Background Thoracic physicians are faced with patients who present with gas in the mediastinum, frequently without an obvious etiologic factor. Published material contains heterogeneous information from which different conclusions can be drawn. Methods In a Medline search from 1990 to 2012, we collected data on mortality, morbidity, signs, symptoms, etiologic factors, and diagnostic methods. Standardized mean differences were calculated. Results We identified 600 patients in 27 papers with series of >5 patients without precipitating or etiologic factors previous to the clinical presentation, but athletic activity, drug abuse, and history of asthma played an apparent role in the disease process. Most patients complained of thoracic pain and dyspnea, with subcutaneous emphysema and Hamman’s sign. The most common complication was tension pneumothorax. Morbidity was seen in 2.8%; no mortality has been reported so far. Conclusion Spontaneous pneumomediastinum is a rare disease with a benign course, which should be treated conservatively unless a complication mandates an invasive procedure. An algorithm for diagnosis and treatment is offered, based on the available evidence.

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.

Ascending necrotizing mediastinitis secondary to emphysematous pyelonephritis

Mediastinal infections usually originate from postoperative complications or in a descending manner from a cervical infectious process; few reports have emerged describing an ascending trajectory. A 56-year-old woman with a Huang class 1 left emphysematous pyelonephritis was referred due to a progression of an ascending necrotizing mediastinitis. A left posterolateral thoracotomy was performed, drainage and thorough lavage were carried out with a successful outcome. We believe this is the first reported case of ascending necrotizing mediastinitis secondary to an emphysematous renal infection.

Pierre-Marie-Bamberger syndrome and solitary fibrous tumor: a rare association:

A solitary fibrous tumor originates in the pleura with variable degrees of invasion. Hypertrophic osteoarthropathy, known as Pierre-Marie-Bamberger syndrome, is characterized by clubbing of the fingers due to bone surface and soft tissue calcification, historically known as a bronchogenic carcinoma paraneoplastic syndrome; however, a few cases have been associated with solitary fibrous tumors. We describe the case of a 38-year-old woman who presented with clubbing of the fingers. Studies revealed an intrathoracic fibrous tumor that was successfully treated with improvement in symptoms.

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.

Four lobes of the right lung

A 52-year-old man with type 2 diabetes mellitus was admitted to the emergency room with a 5-day history of pharyngeal infection, cervical enlargement, leukocytosis, and fever. Computed tomography demonstrated heterogeneity of the mediastinal fat with bilateral pleural effusions; descending necrotizing mediastinitis was suspected. Two hours later, a right posterolateral thoracotomy was performed to drain the mediastinal compartments and pleural cavities. During the procedure, 4 lobes of the right lung were seen, with an accessory lobe due to a complete fissure between the superior segment of the lower lobe and the basal segments (Figure 1), with apparently adequate physiologic function. The operation proceeded uneventfully, and the patient was discharged after 16 days. One year later, he was in good condition.

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.