Management of descending necrotizing mediastinitis with severe thoracic empyema using minimally invasive video-assisted thoracoscopic surgery: a case report

Abstract

Background: Descending necrotizing mediastinitis (DNM) is a rare but serious complication of odontogenic or pharyngeal infection spreading into the mediastinum. Very few childhood cases of DNM have been described. Case Description:We report a case of DNM complicated with severe thoracic empyema in a previously healthy 6-year-old girl who was successfully treated using minimally invasive video-assisted thoracoscopic surgery (VATS). The patient presented with odynophagia and dental pain, followed by rapid clinical deterioration including high fever, tachypnea, and left chest pain. As chest computed tomography (CT) revealed features of DNM, she was transferred from the local hospital to our hospital for intensive care.Empirical treatment was started with meropenem and linezolid. However, her tachypnea and dyspnea progressed rapidly. An ultrasound-guided left-sided thoracentesis drained 80 mL of brown sticky pus and the pus culture yielded Streptococcus constellatus. A contrast-enhanced CT scan demonstrated large mediastinal abscess and severe thoracic empyema. We performed debridement and drainage of the mediastinum and pleura using VATS. She recovered and was discharged on hospital day 18.Conclusions: Early diagnosis by cervicothoracic CT and multidisciplinary approaches including intensive care, broad-spectrum antibiotics, and aggressive surgical intervention are crucial to reducing morbidity and mortality. VATS is a minimally invasive and appropriate treatment strategy for children with DNM, especially complicated with thoracic empyema.

Descending necrotising mediastinitis: a rare entity in children

“…DNM is a critical illness that requires appropriate treatment because pharyngeal and mediastinal abscesses can cause airway emergencies, as in our case 12. To successfully treat and recover from DNM, it is crucial to diagnose it quickly and employ a combination of broad-spectrum antibiotics, surgical drainage and intensive medical care 6…”

“…It is usually treated by surgically draining of mediastinal collections 4. While there have been reports of DNM in adults, there have been very few cases reported in children 5 6. In this report, we describe a child with DNM caused by a retropharyngeal abscess.…”

Descending necrotizing mediastinitis caused by Streptococcus constellatus: A case report and review of the literature

“…We searched PubMed database for cases of S constellatus over the last decade and found that almost cases reported abscess formation ranging from the brain, orbit, lung, and mediastinum to the heart, ovaries, kidney, liver, spine, and thighs. [6][7][8][9][10][11] We complied 6 cases of DNM caused by S constellatus, and this was the second case of such severe, rapidly progressing septic shock (Table 1). [11][12][13][14][15][16] In another case, which was also very aggressive, a patient developed necrotizing fasciitis in the maxillofacial region, neck, and upper mediastinum after experiencing cold and fatigue, followed by rapid decompensation with resulting septic shock caused by S constellatus and Klebsiella oxytoca.…”

“…[6][7][8][9][10][11] We complied 6 cases of DNM caused by S constellatus, and this was the second case of such severe, rapidly progressing septic shock (Table 1). [11][12][13][14][15][16] In another case, which was also very aggressive, a patient developed necrotizing fasciitis in the maxillofacial region, neck, and upper mediastinum after experiencing cold and fatigue, followed by rapid decompensation with resulting septic shock caused by S constellatus and Klebsiella oxytoca. As we can see, the patients' age ranged from 6 to 77 years old and the length of stay varied from 14 to 42 days.…”

The importance of individualized surgical treatment of descending necrotizing mediastinitis

“…We have read with interest the study “ Management of descending necrotizing mediastinitis with severe thoracic empyema using minimally invasive video-assisted thoracoscopic surgery: a case report ”, in which Zhang et al presented a case of descending necrotizing mediastinitis (DNM) complicated with severe thoracic empyema in a young girl. This girl was very well treated using minimally invasive video-assisted thoracoscopic surgery (VATS) ( 1 ). We believe that this report is very intriguing and we consider VATS a relevant option in the therapeutic arsenal of the surgeons.…”