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Weekly Chest CasesArchive of Old Cases

Case No : 865 Date 2014-05-26

  • Courtesy of Hwi Ryong Park, Jae Seung Seo, Semin Chong, Yang Soo Kim / Chung-Ang University Hospital
  • Age/Sex 66 / F
  • Chief ComplaintSore throat, palpable neck mass and swelling for three days (PHx;Rheumatoid arthritis on medication)
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5

5 months earlier

Diagnosis With Brief Discussion

Diagnosis
Descending Necrotizing Mediastinitis with Retropharyngeal abscess
Radiologic Findings
Figure 1. Chest radiograph shows no active lesion in both lungs five months ago.
Figure 2. Chest radiograph taken at emergency room shows right paratracheal bulging shadow.
Figure 3, 4 and 5. Next day, enhanced chest and neck CT show low density fluid collection with mild wall enhancement in the mediastinum and retropharyngeal space of the neck, which spaces are connected with the fluid collection or abscess.

Laboratory data at ER showed mild leukocytosis, increase of hs-CRP and ESR. She refused her admission and further study. But next day, she was finally admitted presenting with progressed symptoms including high fever, mental decrease and low blood pressure. Retropharyngeal abscess combined with descending necrotizing mediastinitis was diagnosed by enhanced chest and neck CT, so emergent thoracotomy, mediastinal dissection and surgical drainage were performed. Lots of tissue necrosis and pus were found in mediastinum and retropharyngeal space of the neck. After two months of surgical drainage and medical treatment, she recovered and discharged.
Brief Review
Descending necrotizing mediastinitis (DNM) is a rare and very severe infection (mortality up to 50%) complicating a primary odontogenic or pharyngeal focus. Gravity and negative intrathoracic pressure facilitate the spread of infection. The retropharyngeal space, called as "dangerous space", is rapid spreading route to the mediastinum. The incidence significantly increases in immunocompromised patients.
Clinical symptoms are fever, odynophagia, dysphonia, dry cough, neck swelling and chest pain. Laboratory work-up may show leukocytosis or leucopenia, thrombocytopenia and raised acute phase proteins.
Radiologic imaging plays a vital role in the diagnosis of DNM. Chest X-ray may show mediastinal widening, pleural effusion, pneumomediastinum. Neck and chest CT are more sensitive and may show fluid collections, with or without gas, increased density of cervical fat, or cellulitis, myositis, cervical lymphadenopathy, fluid collection in the mediastinum, pleura, and pericardium and vascular thrombosis. Key point of diagnosis is establishing the pathway for the spread from the neck to the mediastinum.
References
1. Scaglione, Mariano, et al. CT features of descending necrotizing mediastinitis-a pictorial essay. Emergency radiology 14.2 (2007): 77-81.
2. Shaikh, N., et al. Descending necrotizing mediastinitis: Report of three cases and review of literature. Archives of International Surgery 3.2 (2013): 173.
Keywords
Mediastinum, Infection, Bacterial infection,

No. of Applicants : 75

▶ Correct Answer : 35/75,  46.7%
  • - The University of Tokyo Hospital , Japan Akifumi Hagiwara
  • - Niigata City General Hospital , Japan Takao Kiguchi
  • - UWO , Canada S Lee
  • - Nagasaki University Hospital, Department of Pathology , Japan TOMONORI TANAKA
  • - radiologist, aditya imaging centre , India vivek patel
  • - GHICL , France manuel toledano
  • - Seirei Hamamatsu General Hospital , Japan Kenichi Mizuki
  • - Kyung Hee University Hospital at Gangdong , Korea (South) Seong Jong Yun
  • - National Hospital Organization Okinawa Hospital , Japan Yasuji Oshiro
  • - Samsung medical center , Korea (South) Hyun Su Kim
  • - The University of Tokyo Hospital , Japan Takeyuki Watadani
  • - Seoul National University Hospital , Korea (South) Sang Min Lee
  • - barnard institute or radiology , India karnan sudha
  • - Goa Medical College , India Paresh Desai
  • - Royal Perth Hospital , Australia Yuranga Weerakkody
  • - McGill University Health Center , Canada Alexandre Semionov
  • - Deptt of Radiodiagnosis & Imaging, PGIMER chandigarh , India Ram Galwa
  • - Japanese national center hospital of neurology and psychiatry , Japan Kaoru Sumida
  • - Chonnam university hospital , Korea (South) Jang mi Baek
  • - Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
  • - 異⑸ , Korea (South) Yunhee Jang
  • - IRSA La Rochelle , France Denis Chabassiere
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - Shiga University of Medical Science , Japan Akitoshi Inoue
  • - Kizawa Memorial Hospital , Japan Yo Kaneko
  • - Sanggye paik hospital , Korea (South) Kyungsun Nam
  • - ICD,MCH CALICUT , India rikhy krishnan
  • - Kobe City Medical Center General Hospital , Japan Yasuhisa Kurata
  • - Saint Malo , France jean-baptiste Noel
  • - CLINIQUE STE CLOTILDE , Reunion patrick MASCAREL
  • - Onomichi municipal hospital , Japan Toshiyuki Komaki
  • - ZIGONG TCM HOSPITAL OF CHINA , China Cao Cunyou
  • - The University of Tokyo Hospital , Japan Takana Yamakawa
  • - Medicheck health care , Korea (South) Chae Lim
  • - Gachon Gil hospital , Korea (South) junhyung Ann
▶ Correct Answer as Differential Diagnosis : 11/75,  14.7%
  • - Medical College Chest Hospital,Thrissur,Kerala , India Raveendran TK
  • - Oita University, Faculty of Medicine , Japan Fumito Okada
  • - Korea university anam hospital , Korea (South) Sung-Hye You
  • - Kyoto University , Japan Akihiko Sakata
  • - Kanto Rosai Hospital , Japan tomoko sako
  • - jaslok hospital & research centre mumbai , India JAINENDRA JAIN
  • - Onomichi municipal hospital , Japan Hirofumi Mifune
  • - NASA SCANS , India RAKESH BHATIA
  • - Chungbuk national university , Korea (South) Yong Kim
  • - Pneumologia Universitaria, Policlinico di Bari , Italy Mario Damiani
  • - Chonnam National University Hospital , Korea (South) Sungmin Moon
▶ Semi-Correct Answer : 20/75,  26.7%
  • - Avrasya Hospital , Turkey Murat Ulusoy
  • - Chonnam national univ. hospital , Korea (South) Choi Seul-Gi
  • - HH.CNU , Korea (South) Jung hyun Kim
  • - Jichi Medical University Hospital , Japan Yuichiro Kawahara
  • - SALMAN IBN ABDULAZIZ UNIVERSITY HOSPITAL , Saudi Arabia Elbagir Nasser
  • - Khoo Teck Phuat Hospital Singapore , Singapore ashish chawla
  • - stanley medical college , India mahes waran
  • - NIMS, HYDERABAD , India bhaskar kakarla
  • - Ondokuz Mayis University , Turkey Cetin Celenk
  • - University of British Columbia , Canada Amr Ajlan
  • - Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
  • - 異⑸ , Korea (South) Junghwan Kim
  • - Asan medical center , Korea (South) Sang Young Oh
  • - Centre Imagerie de Fribourg , Switzerland Benoit Rizk
  • - CLCC Rennes , France nicolas gautier
  • - the First Affiliated Hospital of NanJing Medical University , China Aiping Chen
  • - All India Institute of Medical Sciences , India Ashish Gupta
  • - Private sector , Greece Vasilios Tzilas
  • - Chonnam national university hospital , Korea (South) INSOO JANG
  • - Hopital Bichat , France, Metropolitan Pauline Pradere
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