Fungal Cervical Abscess Complicated by Necrotizing Fasciitis Leading to Descending Necrotizing Mediastinitis: A Case Report

Abstract

Cervical necrotizing fasciitis (CNF) is a rapidly spreading deep neck infection with a high mortality rate if left untreated. The occurrence of necrotizing infections in the head and neck region is uncommon; therefore, it is a rare cause of chest pain presenting to the emergency department. Here, we present an interesting case of fungal cervical skin abscess complicated by necrotizing fasciitis that progressed to involve the mediastinum, causing necrotizing mediastinitis with pneumomediastinum in an elderly female. The patient presented to the emergency department with chest pain, shortness of breath, and fever. She had a 10-day history of a mass in the anterior midline of her neck with odynophagia. After radiologic confirmation, she was taken to the operating room where she underwent incision and drainage with debridement and washout. Postoperatively, she was given broad-spectrum antibiotics empirically, which were later replaced with intravenous (I/V) fluconazole after culture reports. Prompt diagnosis and treatment lead to the early recovery of the patient and subsequent discharge without any complications. We report this case to draw the attention of emergency medicine physicians and clinicians to this rare and life-threatening but treatable condition. Expeditious diagnosis and treatment lead to early recovery and fewer postoperative complications.

Necrotizing fasciitis of the chest wall: A clinical case report and literature review

“…The secondary ones involve a specific flora and a specific behavior. The more frequent deep cervical infectious processes are associated with mediastinitis due to the cervical fascial anatomy and their connections to the mediastinal fasciae (11). The superficial ones also expand gravitationally, but superficially developing fasciitis of the chest wall, with the aggravation of the initial prognosis (11,(13)(14)(15)(16)(17)(18)(19)(20).…”

“…The more frequent deep cervical infectious processes are associated with mediastinitis due to the cervical fascial anatomy and their connections to the mediastinal fasciae (11). The superficial ones also expand gravitationally, but superficially developing fasciitis of the chest wall, with the aggravation of the initial prognosis (11,(13)(14)(15)(16)(17)(18)(19)(20). The most common causes include dental abscesses, but have also been cited as secondary to Bezold abscesses or to puncture site for central catheterization.…”

“…In the literature, the bacteria involved in the pathogenesis of necrotizing parietal fasciitis is termed ‘flesh eating bacteria’, although there is no proper mechanism of ‘tissue devouring’. The mechanisms of the bacteria involved are multiple and include bacterial necrotoxins ( Clostridium perfringens , Streptococcus pyogenes ), thrombosis and microvascular coagulation with secondary necrosis by heparinase release, anaerobic environment, release of beta lactamases that interfere with antibiotic activity ( 2 , 4 , 11 ).…”

“…In most cases, it has been shown to be directly related to the state of immunodeficiency, secondary to an unbalanced diabetes mellitus, steroid treatment, hematological or oncological disease (8)(9)(10)(11). This proven link does not exclude the possibility of this pathology in an apparently immunocompetent patient.…”

Odontogenic cervical necrotizing fasciitis with descending mediastinitis: a case report and discussion

“…5,15 Fungal co-infection in DNM is less common and has only been described twice, one which occurred primarily as a deep neck space infection and another that developed from a surgical site infection after total thyroidectomy. 16,17 Empirical antibiotics for necrotising fasciitis (regardless of location) in our institution includes penicillin G, vancomycin and clindamycin which was adequate to treat the bacteria isolated from initial cultures but repeated cultures should be routinely taken to check for other pathogens and secondary infections. Vigilance should be practiced to periodically update empirical antibiotic regimes to keep up with changing microbial trends.…”