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Ann Thorac Surg 1999;68:1443
© 1999 The Society of Thoracic Surgeons

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Correspondence

Further descent of descending necrotizing mediastinitis

^a Department of Pathology Seth G.S. Medical College & K.E.M. Hospital, Parel, Mumbai-400012, India
^b Department of Chest Medicine, Seth G.S. Medical College & K.E.M. Hospital, Parel, Mumbai-400012, India

To the Editor

Descending necrotizing mediastinitis is a life-threatening complication of an oropharyngeal infection that requires prompt and aggressive medical and surgical therapy [1]. Further spread of the infection into the retroperitoneal space has not been described before and we encountered such a phenomenon in a human immunodeficiency virus-positive individual. A 35-year-old man complained of an inability to open the mouth and difficulty in swallowing solids and liquids, with swelling in the submandibular region for 2 days.He was poorly nourished with extensive dental caries of the premolars and molars in both jaws.The clinical diagnosis was that of Ludwig’s angina and septicemia. He died within 18 hours of admission.

At autospy, there was a yellowish green, dirty exudate in the submental submandibular regions and the neck. Similar pus encased the heart, formed a thick film over the hilar surfaces of the lung and enveloped the trachea, esophagus, and aorta. Interestingly, the purulent exudate also had extended into the retroperitoneum covering the abdominal aorta, and hilar and posterior surfaces of the kidney. Gram stain smears revealed gram-positive cocci and gram-negative bacilli. Acid fast bacilli were not identified. Blood collected at autopsy revealed the patient to be positive for human immunodeficiency virus. Tuberculous meningitis, pulmonary miliary tuberculosis, and mesenteric tuberculous lymphadenitis were other necropsy findings.

The spread of an oropharyngeal infection to the neck and mediastinum is aided by the absence of barriers in the facial planes and also by gas formation of the organisms. It is important to remember that a transdiaphragmatic spread via the various hiatuses can also occur especially in an immunocompromised person. Because successful treatment depends on both medical and surgical modalities, it is imperative to rule out peritoneal or retroperitoneal involvement.

References

1. Kiernan P.D., Hernandez Z., Byrne W.D., et al. Descending cervical mediastinitis. Ann Thorac Surg 1998;65:1483-1488.[Abstract/Free Full Text]

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