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The American Journal of Case Reports Jan 2021BACKGROUND Fibrosing mediastinitis is a rarely seen, progressive disease. It results from an excessive fibrotic reaction in the mediastinum. We describe a presentation...
BACKGROUND Fibrosing mediastinitis is a rarely seen, progressive disease. It results from an excessive fibrotic reaction in the mediastinum. We describe a presentation of fibrosing mediastinitis that, to our knowledge, has never been seen before. CASE REPORT A 30-year-old female Colombian flight attendant presented with a right eyelid droop. Examination revealed partial right-sided ptosis and miosis but no anhidrosis. An ill-defined firm swelling was palpable at the root of the neck. Chest radiography revealed a widened mediastinum, and computerized tomography (CT) showed a right paratracheal mass without calcification extending to the thoracic inlet, encasing multiple blood vessels. All basic blood tests, magnetic resonance imaging of the head, and ultrasound Doppler of the neck vessels were normal. History and work up for infections including fungal diseases, granulomatous diseases, vasculitis, and autoimmune diseases were negative. Positron emission tomography (PET) showed significant FDG uptake in the mediastinum. Mediastinal biopsy was histologically consistent with fibrosing mediastinitis. All relevant immunohistochemistry and microbiological studies were negative. Subsequently, the patient developed signs of superior vena cava compression; this was managed by balloon angioplasty, which resulted in improvement of symptoms. However, over time, her symptoms worsened progressively, resulting in a left-sided ptosis and radiological progression of the mass on CT. She received treatment with rituximab and concomitant steroids, which yielded excellent results: the treatment led to both resolution of her symptoms and regression of the mass and its metabolic activity on PET scan. CONCLUSIONS Fibrosing mediastinitis can present with an incomplete Horner's syndrome. Treatment with rituximab and steroids shows promising results in select cases of metabolically active idiopathic fibrosing mediastinitis.
Topics: Adult; Blepharoptosis; Female; Humans; Mediastinitis; Miosis; Sclerosis
PubMed: 33431787
DOI: 10.12659/AJCR.927556 -
International Journal of Infectious... Jan 2020The aim of this study was to elaborate on and validate a score for the early diagnosis of mediastinitis after cardiothoracic surgery.
OBJECTIVES
The aim of this study was to elaborate on and validate a score for the early diagnosis of mediastinitis after cardiothoracic surgery.
METHODS
Between 2007 and 2017, patients who experienced thoracic surgical-site infection after cardiothoracic surgery were enrolled. Laboratory, clinical, and chest CT findings were retrospectively analyzed. Patients were followed up until hospital discharge or intra-hospital death. Univariate and multivariate regression analyses were performed.
RESULTS
950 surgical-site infections were found and analyzed (131 mediastinitis, 819 superficial/deep infections). Of the 131 mediastinitis episodes, 88% required surgical thoracic debridement,Staphylococcus aureus was identified in 43%, and overall mortality was 42%. The following variables were related to mediastinitis diagnosis: sternal diastasis (OR=2.5; 95% confidence interval [95%CI]: 1.2-5.3; P=0.012), bilateral pleural effusion (OR=1.9; 95%CI: 1.0-3.6; P=0.04), leukocyte count ≥14,000cells/mm (OR=2.5; 95%CI: 1.3-4.7; P=0.006), male sex (OR=2; 95%CI: 1.11-4; P=0.022), and positive blood culture (OR=3.0; 95%CI: 1.6-5.6; P=0.001). The score predicted with reasonable accuracy mediastinitis in the derivation cohort (AUC-ROC, 0.7476) and the validation cohort (AUC-ROC, 0.7149). Groups with high (31%) and low (5%) risk of mediastinitis were identified.
CONCLUSIONS
An early diagnostic score in patients with surgical-site infection after cardiothoracic surgery identified groups with a low and high risk for mediastinitis.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Child; Child, Preschool; Cohort Studies; Female; Humans; Male; Mediastinitis; Middle Aged; Retrospective Studies; Staphylococcal Infections; Staphylococcus aureus; Sternum; Surgical Wound Infection; Thoracic Surgical Procedures; Young Adult
PubMed: 31525520
DOI: 10.1016/j.ijid.2019.09.010 -
The Annals of Thoracic Surgery Sep 2009
Topics: Esophageal Fistula; Esophageal Perforation; Esophagectomy; Esophagoscopy; Follow-Up Studies; Humans; Mediastinitis; Reoperation; Sepsis; Surgical Flaps
PubMed: 19699930
DOI: 10.1016/j.athoracsur.2009.06.016 -
Sao Paulo Medical Journal = Revista... Sep 2006Mediastinitis is an inflammation of connective tissue that involves mediastinal structures. When the condition has an infectious origin located in the cervical or oral... (Review)
Review
CONTEXT
Mediastinitis is an inflammation of connective tissue that involves mediastinal structures. When the condition has an infectious origin located in the cervical or oral region, it is termed "descending mediastinitis" (DM).
DATA SOURCES
The subject was examined in the light of the authors' own experiences and by reviewing the literature available on the subject. The Medline, Lilacs and Cochrane databases were searched for articles, without time limits, screening for the term "descending mediastinitis". The languages used were English and Spanish.
DATA SYNTHESIS
There are three main fascial pathways by which oral or cervical infections can reach the mediastinum: pretracheal, lateropharyngeal and retropharyngeal. About 70% of DM cases occur via the retropharyngeal pathway. The mortality rate is about 50%. According to infection extent, as seen using computed tomography, DM can be classified as focal (type I) or diffuse (type II). The clinical manifestations are nonspecific and resemble other systemic infections or septic conditions. The primary treatment for DM consists of antibiotics and surgical drainage. There are several approaches to treating DM; the choice of approach depends on the DM type and the surgeon's experience. In spite of all the improvements in knowledge of the microbiology and physiopathology of the disease, controversies still exist regarding the ideal duration of antibiotic therapy and whether tracheostomy is really a necessary procedure.
CONCLUSION
Since DM is a lethal condition if not promptly treated, it must always be considered to represent an emergency situation.
Topics: Humans; Mediastinitis; Tomography, X-Ray Computed
PubMed: 17262162
DOI: 10.1590/s1516-31802006000500011 -
European Journal of Cardio-thoracic... Oct 2012Descending necrotizing mediastinitis (DNM) is a rare but rapidly progressing disease with a potentially fatal outcome, originating from odontogenical or cervical... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
Descending necrotizing mediastinitis (DNM) is a rare but rapidly progressing disease with a potentially fatal outcome, originating from odontogenical or cervical infections. The aim of this article was to give an up-to-date overview on this still underestimated disease, to draw the clinician's attention and particularly to highlight the need for rapid diagnosis and adequate surgical treatment.
METHODS
We present a retrospective analysis of 17 patients diagnosed and treated for advanced DNM between 1999 and 2011 in a tertiary referral medical centre. Hence, this is one of the largest single-centre studies in recent years concerning the diffuse form (i.e. extending into the lower mediastinum) of DNM. Subsequently, we analysed and compared the international literature with our data, with the focus on surgical management and outcome.
RESULTS
In our series of 17 adult patients, 16 were surgically treated by median sternotomy (n = 8) or the clamshell (n = 8) approach for diffuse DNM. One patient, referred with septic shock, died 2 days after surgery. The median interval from diagnosis of DNM by cervicothoracic computed tomography scan and thoracic surgery was 6 h (range 1-24 h) in all but the one patient with fatal outcome (48 h). Concomitant cervicotomy was performed in 11 patients (65%) and tracheotomy in 9 (53%). The median duration of hospitalization was 16 days (range 4-50 days), including an intensive care unit stay of 4 days (range 1-50 days).
CONCLUSIONS
For DNM limited to the upper part of the mediastinum, which applies to the majority of cases, a transcervical approach and drainage may be sufficient. In advanced disease, extending below the tracheal carina, an immediate and more aggressive surgical approach is required to combat a much higher morbidity and mortality in this subset of patients. A timely situational approach via median sternotomy or a clamshell incision allowed us to maintain a very low morbidity, mortality and rate of reoperations, without major complications due to the surgical approach itself.
Topics: Adult; Aged; Drainage; Female; Gram-Negative Bacterial Infections; Gram-Positive Bacterial Infections; Humans; Length of Stay; Male; Mediastinitis; Mediastinum; Middle Aged; Neck; Necrosis; Postoperative Complications; Retrospective Studies; Sternotomy; Tomography, X-Ray Computed; Tracheotomy; Treatment Outcome
PubMed: 22761501
DOI: 10.1093/ejcts/ezs385 -
Texas Heart Institute Journal 2013The consequences of deep wound infections before, during, and after coronary artery bypass grafting have prompted research to clarify risk factors and explore preventive... (Review)
Review
The consequences of deep wound infections before, during, and after coronary artery bypass grafting have prompted research to clarify risk factors and explore preventive measures to keep infection rates at an irreducible minimum. An analysis of 42 studies in which investigators used multivariate logistic regression analysis revealed that diabetes mellitus and obesity are by far the chief preoperative risk factors. A 4-point preoperative scoring system based on a patient's body mass index and the presence or absence of diabetes is one practical way to determine the risk of mediastinitis, and other risk-estimate methods are being refined. Intraoperative risk factors include prolonged perfusion time, the use of one or more internal mammary arteries as grafts, blood transfusion, and mechanical circulatory assistance. The chief postoperative risk factor is reoperation, usually for bleeding. Unresolved issues include the optimal approach to Staphylococcus aureus nasal colonization and the choice of a prophylactic antibiotic regimen. We recommend that cardiac surgery programs supplement their audit processes and ongoing vigilance for infections with periodic, multidisciplinary reviews of best-practice standards for preoperative, intraoperative, and postoperative patient care.
Topics: Antibiotic Prophylaxis; Coronary Artery Bypass; Guideline Adherence; Humans; Infection Control; Logistic Models; Mediastinitis; Multivariate Analysis; Practice Guidelines as Topic; Practice Patterns, Physicians'; Quality of Health Care; Risk Assessment; Risk Factors; Surgical Wound Infection; Treatment Outcome
PubMed: 23678210
DOI: No ID Found -
Emergency Medicine Journal : EMJ Jan 2004Descending necrotising mediastinitis rarely develops and this variety of mediastinitis is a highly lethal disease. A case is reported of descending necrotising... (Review)
Review
Descending necrotising mediastinitis rarely develops and this variety of mediastinitis is a highly lethal disease. A case is reported of descending necrotising mediastinitis caused by an odontogenic infection. The importance is emphasised of prompt diagnosis and aggressive surgical mediastinal drainage for the survival of these patients. Most acute mediastinal infections result from oesophageal perforation, either secondary to oesophagoscopy or tumour erosion. Mediastinitis occasionally develops as descending necrotising mediastinitis originating from the complications of cervical or odontogenic infections. Descending necrotising mediastinitis usually has a fulminant course, leading commonly to sepsis and death.
Topics: Adolescent; Bicuspid; Emergencies; Fatal Outcome; Female; Focal Infection, Dental; Humans; Mediastinitis; Necrosis; Periodontal Abscess
PubMed: 14734401
DOI: 10.1136/emj.2003.002865 -
Diagnostic and Interventional Radiology... 2015The posterior mediastinum contains several structures that can produce a wide variety of pathologic conditions. Descending thoracic aorta, esophagus, azygos and... (Review)
Review
The posterior mediastinum contains several structures that can produce a wide variety of pathologic conditions. Descending thoracic aorta, esophagus, azygos and hemiazygos veins, thoracic duct, lymph nodes, adipose tissue, and nerves are all located in this anatomical region and can produce diverse abnormalities. Although chest radiography may detect many of these pathologic conditions, computed tomography and magnetic resonance are the imaging modalities of choice for further defining the relationship of posterior mediastinal lesions to neighboring structures and showing specific imaging features that narrow the differential diagnosis. This review emphasizes modality-related answers to morphologic questions, which provide precise diagnostic information.
Topics: Humans; Magnetic Resonance Imaging; Mediastinum; Multimodal Imaging; Thoracic Neoplasms; Tomography, X-Ray Computed
PubMed: 25993732
DOI: 10.5152/dir.2014.14467 -
Medicine Nov 2015Fibrosing mediastinitis is caused by a proliferation of fibrous tissue in the mediastinum with encasement of mediastinal viscera and compression of mediastinal... (Observational Study)
Observational Study
Fibrosing mediastinitis is caused by a proliferation of fibrous tissue in the mediastinum with encasement of mediastinal viscera and compression of mediastinal bronchovascular structures. Pulmonary hypertension (PH) is a severe complication of fibrosing mediastinitis caused by extrinsic compression of the pulmonary arteries and/or veins.We have conducted a retrospective observational study reviewing clinical, functional, hemodynamic, radiological characteristics, and outcome of 27 consecutive cases of PH associated with fibrosing mediastinitis diagnosed between 2003 and 2014 at the French Referral Centre for PH.Fourteen men and 13 women with a median age of 60 years (range 18-84) had PH confirmed on right heart catheterization. The causes of fibrosing mediastinitis were sarcoidosis (n = 13), tuberculosis-infection confirmed or suspected (n = 9), mediastinal irradiation (n = 2), and idiopathic (n = 3). Sixteen patients (59%) were in NYHA functional class III and IV. Right heart catheterization confirmed moderate to severe PH with a median mean pulmonary artery pressure of 42 mm Hg (range 27-90) and a median cardiac index of 2.8 L/min/m (range 1.6-4.3). Precapillary PH was found in 22 patients, postcapillary PH in 2, and combined postcapillary and precapillary PH in 3. Severe extrinsic compression of pulmonary arteries (>60% reduction in diameter) was evidenced in 2, 8, and 12 patients at the main, lobar, or segmental levels, respectively. Fourteen patients had at least one severe pulmonary venous compression with associated pleural effusion in 6 of them. PAH therapy was initiated in 7 patients and corticosteroid therapy (0.5-1 mg/kg/day) was initiated in 3 patients with sarcoidosis, with 9 other being already on low-dose corticosteroids. At 1-year follow-up, 3 patients had died and among the 21 patients evaluated, 3 deteriorated, 14 were stable, and only 4 patients with sarcoidosis improved (4 receiving corticosteroids and 1 receiving corticosteroids and PAH therapy). Survival was 88%, 73%, and 56% at 1, 3, and 5 years, respectively.We found no clear clinical improvement with the use of specific PAH therapy. Corticosteroid therapy may be associated with clinical improvement, in some patients with fibrosing mediastinitis due to sarcoidosis. Although never performed for this indication, lung transplantation may be proposed in eligible patients with severe PH and fibrosing mediastinitis.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Cardiac Catheterization; Female; Humans; Hypertension, Pulmonary; Male; Mediastinitis; Middle Aged; Pulmonary Wedge Pressure; Retrospective Studies; Sclerosis; Tomography, X-Ray Computed
PubMed: 26554778
DOI: 10.1097/MD.0000000000001800 -
International Journal of Environmental... Feb 2023Head and neck infections are commonly caused by affections with an odontogenic origin. Untreated or non-responsive to treatment odontogenic infections can cause severe... (Observational Study)
Observational Study
BACKGROUND
Head and neck infections are commonly caused by affections with an odontogenic origin. Untreated or non-responsive to treatment odontogenic infections can cause severe consequences such as localized abscesses, deep neck infections (DNI), and mediastinitis, conditions where emergency procedures such as tracheostomy or cervicotomy could be needed.
METHODS
An epidemiological retrospective observational study was performed, and the objective of the investigation was to present a single-center 5-years retrospective analysis of all patients admitted to the emergency department of the hospital Policlinico Umberto I "Sapienza" with a diagnosis of odontogenic related head and neck infection, observing the epidemiological patterns, the management and the type of surgical procedure adopted to treat the affections.
RESULTS
Over a 5-year period, 376,940 patients entered the emergency room of Policlinico Umberto I, "Sapienza" University of Rome, for a total of 63,632 hospitalizations. A total of 6607 patients were registered with a diagnosis of odontogenic abscess (10.38%), 151 of the patients were hospitalized, 116 of them were surgically treated (76.8%), and 6 of them (3.9%) manifested critical conditions such as sepsis and mediastinitis.
CONCLUSIONS
Even today, despite the improvement of dental health education, dental affections can certainly lead to acute conditions, necessitating immediate surgical intervention.
Topics: Humans; Abscess; Retrospective Studies; Mediastinitis; Neck; Communicable Diseases
PubMed: 36834169
DOI: 10.3390/ijerph20043469