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Acupuncture: a cause of mediastinal abscess presenting as axillary infection A 67-year-old man presented to the emergency department with a 2-day history of rigors and left upper chest wall pain extending into the axilla. He had attended the same department 2 weeks prior, after gardening with a non-penetrative traumatic 5 × 5 cm intramuscular pectoral haematoma, confirmed by ultrasound. This was managed with analgesics. He later sought acupuncture for further pain relief (needle placement indicated in Fig. 1). On examination on this occasion, there was a 10 × 6 cm fluctuant discharging axillary abscess (A) and a second indurated erythematous area inferior to left clavicular head (B) (Fig. 1). The patient had a raised white cell count of 21 × 109/L. He was treated with intravenous antibiotics and surgery where abscess (A) was drained and exploration of the indurated area (B) showed no communication despite widespread induration between the two sites. The erythema persisted over area (B) post-operatively and ultrasound revealed a fluid collection below the left clavicle and review of chest X-ray (CXR) showed mediastinal widening, suggestive of a mediastinal collection (Fig. 2). Comput-
erized tomography (CT) showed an 82 × 42 mm anterior mediastinal collection (Fig. 3). Operative drainage was performed using a Yates drain through the left second intercostal space and the chest wall surgical sites were re-explored. There was a communication between the mediastinal abscess and the sub-clavicular induration
Fig. 2. Chest X-ray showing mediastinal widening, soft tissue swelling in the left axilla and a linear opacification in left lower zone consistent with atelectasis.
Fig. 1. Photograph taken at presentation of an axillary abscess (label A) and an indurated abscess below the clavicular head (label B). The acupuncture needle positioning is indicated with black circles.
© 2015 Royal Australasian College of Surgeons
Fig. 3. Computerized tomography scan of the thorax showing a complex intrathoracic collection containing gas within the anterior mediastinum space.
ANZ J Surg •• (2015) ••–••
2
(B) but induration only to drained abscess (A). Planned re-exploration was performed 4 days later where the Yates drain was replaced with a 24-Fr drain into mediastinal space. The patient was investigated for other sources of mediastinal sepsis including, transthoracic echocardiogram, ENT examinations and blood cultures, which were all negative. Pus cultures grew Staphylococcus aureus. He was discharged with 6 weeks of intravenous vancomycin, followed by a 3- to 6-month course of oral clindamycin. Anterior mediastinal abscesses are rare and typically arise from head and neck infections due to the continuity between the mediastinum and pre-tracheal space of the neck. Other common causes include trauma, median sternotomy in cardiothoracic surgery and oesophageal perforation. A small proportion of mediastinal abscesses originate from infections in the anterior chest.1 Mediastinal abscesses are usually diagnosed on radiological imaging. Suspicious primary signs on CXR include mediastinal widening, air fluid levels and subcutaneous or mediastinal emphysema or secondary complications such as pleural effusion or pneumoperitoneum.2 CT is the gold standard for a definitive diagnosis to delineate the size and extension of the abscess.3 The most likely aetiology in this case was acupuncture, leading to inoculation of skin Staphylococcus organisms (confirmed on pus culture) into the pectoral haematoma resulting in two discharging points, the lateral discharging via the axilla (A) and the medial (B) tracking deeper and discharging into the mediastinum. The alternative explanation of a spontaneous mediastinal abscess presenting as a chest wall abscess is less likely, especially in absence of any predisposing source of sepsis. Acupuncture is an unusual cause of abscess. One systematic review reported eight acupuncture-related abscesses, three of which were attributed to unsterile technique. Abscess sites included intracranial, buccal, temporal, gluteal and lower back.4 Another review reported 239 acupuncture-related infections in 25 countries between 2000 and 2011, eight in Australia.5 Another outbreak of six methicillin-resistant Staphylococcus aureus acupuncture-related infections between 2003 and 2004 was also reported.6 Acupuncture leading to chest wall and/or anterior mediastinal abscesses or its infectious tracking to distal sites has not been reported. Acute mediastinitis carries up to 40% mortality rate and is treated with intravenous broad spectrum antibiotics and various surgical drainage approaches including radical transcervical and transthoracic approaches.1,7 We highlight the need for a high index of suspicion in the assessment of any deep mediastinal abscess, especially in patients with recent haematoma with potential needle-tracking of infection. Furthermore, unresolving abscesses should suggest the need for early re-imaging rather than simple surgical re-exploration. Prognosis in this case was favourable due to early drainage of the abscess and aggressive antibiotic treatment prior to the CT, followed
Images for surgeons
by early drainage of the mediastinal abscess. This facilitated the use of a minimally invasive strategy of local drainage rather than the need for a radical thoracotomy approach. Antimicrobial therapy in conjunction with surgical debridement decreases mortality risk by 40%.8 In summary, this is the first documented case of an acupuncture event leading to mediastinal abscess formation. Clinicians and patients need to be aware of some of the potential risks of acupuncture, particularly infection. In addition, the possibility of deep tracking should be considered in unresolving, but seemingly benign abscess. With early clinician awareness and diagnosis, the potentially catastrophic complications of mediastinal abscesses can be treated successfully with minimally invasive techniques.
References 1. Xu QY, Yin GW, Chen X, Jiang F, Bai XJ, Wu JD. Fluoroscopically guided nose tube drainage of mediastinal abscesses in post-operative gastro-oesophageal anastomotic leakage. Br. J. Radiol. 2012; 85: 1477– 81. 2. Mandell GL, Bennett JE, Dolin R. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases, 7th edn. Philadelphia: Churchill Livingstone, 2010; 1173–82. Chapter 82. 3. Kouritas VK, Zissis C, Bellenis I. Staphylococcal isolated anterosuperior mediastinal abscess of unknown origin. Interact. Cardiovasc. Thorac. Surg. 2012; 14: 650–1. 4. Zhang J, Shang H, Gao X, Ernst E. Acupuncture-related adverse events: a systematic review of the Chinese literature. Bull. World Health Organ. 2010; 88: 915–21. 5. Xu S, Wang L, Cooper E et al. Adverse events of acupuncture: a systematic review of case reports. Evid. Based Complement. Alternat. Med. 2013; 2013: 581203. 6. Murray RJ1, Pearson JC, Coombs GW et al. Outbreak of invasive methicillin-resistant Staphylococcus aureus infection associated with acupuncture and joint injection. Infect. Control Hosp. Epidemiol. 2008; 29: 859–65. 7. Kang SK, Lee S, Oh HK et al. Clinical features of deep neck infections and predisposing factors for mediastinal extension. Korean J. Thorac. Cardiovasc. Surg. 2012; 45: 171–6. 8. Karra R, McDermott L, Connelly S et al. Risk factors for 1-year mortality after postoperative mediastinitis. J. Thorac. Cardiovasc. Surg. 2006; 132: 537–43.
Luke Traeger,* MBBS Marrillo Jayasuriya,† BSc, MBBS Aravind Suppiah,† MD, FRCS Peter G. Devitt,*† MS, FRACS *School of Medicine, University of Adelaide, Adelaide, South Australia, Australia and †Discipline of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia doi: 10.1111/ans.13010
© 2015 Royal Australasian College of Surgeons
Acupuncture: a cause of mediastinal abscess presenting as axillary infection A 67-year-old man presented to the emergency department with a 2-day history of rigors and left upper chest wall pain extending into the axilla. He had attended the same department 2 weeks prior, after gardening with a non-penetrative traumatic 5 × 5 cm intramuscular pectoral haematoma, confirmed by ultrasound. This was managed with analgesics. He later sought acupuncture for further pain relief (needle placement indicated in Fig. 1). On examination on this occasion, there was a 10 × 6 cm fluctuant discharging axillary abscess (A) and a second indurated erythematous area inferior to left clavicular head (B) (Fig. 1). The patient had a raised white cell count of 21 × 109/L. He was treated with intravenous antibiotics and surgery where abscess (A) was drained and exploration of the indurated area (B) showed no communication despite widespread induration between the two sites. The erythema persisted over area (B) post-operatively and ultrasound revealed a fluid collection below the left clavicle and review of chest X-ray (CXR) showed mediastinal widening, suggestive of a mediastinal collection (Fig. 2). Comput-
erized tomography (CT) showed an 82 × 42 mm anterior mediastinal collection (Fig. 3). Operative drainage was performed using a Yates drain through the left second intercostal space and the chest wall surgical sites were re-explored. There was a communication between the mediastinal abscess and the sub-clavicular induration
Fig. 2. Chest X-ray showing mediastinal widening, soft tissue swelling in the left axilla and a linear opacification in left lower zone consistent with atelectasis.
Fig. 1. Photograph taken at presentation of an axillary abscess (label A) and an indurated abscess below the clavicular head (label B). The acupuncture needle positioning is indicated with black circles.
© 2015 Royal Australasian College of Surgeons
Fig. 3. Computerized tomography scan of the thorax showing a complex intrathoracic collection containing gas within the anterior mediastinum space.
ANZ J Surg •• (2015) ••–••
2
(B) but induration only to drained abscess (A). Planned re-exploration was performed 4 days later where the Yates drain was replaced with a 24-Fr drain into mediastinal space. The patient was investigated for other sources of mediastinal sepsis including, transthoracic echocardiogram, ENT examinations and blood cultures, which were all negative. Pus cultures grew Staphylococcus aureus. He was discharged with 6 weeks of intravenous vancomycin, followed by a 3- to 6-month course of oral clindamycin. Anterior mediastinal abscesses are rare and typically arise from head and neck infections due to the continuity between the mediastinum and pre-tracheal space of the neck. Other common causes include trauma, median sternotomy in cardiothoracic surgery and oesophageal perforation. A small proportion of mediastinal abscesses originate from infections in the anterior chest.1 Mediastinal abscesses are usually diagnosed on radiological imaging. Suspicious primary signs on CXR include mediastinal widening, air fluid levels and subcutaneous or mediastinal emphysema or secondary complications such as pleural effusion or pneumoperitoneum.2 CT is the gold standard for a definitive diagnosis to delineate the size and extension of the abscess.3 The most likely aetiology in this case was acupuncture, leading to inoculation of skin Staphylococcus organisms (confirmed on pus culture) into the pectoral haematoma resulting in two discharging points, the lateral discharging via the axilla (A) and the medial (B) tracking deeper and discharging into the mediastinum. The alternative explanation of a spontaneous mediastinal abscess presenting as a chest wall abscess is less likely, especially in absence of any predisposing source of sepsis. Acupuncture is an unusual cause of abscess. One systematic review reported eight acupuncture-related abscesses, three of which were attributed to unsterile technique. Abscess sites included intracranial, buccal, temporal, gluteal and lower back.4 Another review reported 239 acupuncture-related infections in 25 countries between 2000 and 2011, eight in Australia.5 Another outbreak of six methicillin-resistant Staphylococcus aureus acupuncture-related infections between 2003 and 2004 was also reported.6 Acupuncture leading to chest wall and/or anterior mediastinal abscesses or its infectious tracking to distal sites has not been reported. Acute mediastinitis carries up to 40% mortality rate and is treated with intravenous broad spectrum antibiotics and various surgical drainage approaches including radical transcervical and transthoracic approaches.1,7 We highlight the need for a high index of suspicion in the assessment of any deep mediastinal abscess, especially in patients with recent haematoma with potential needle-tracking of infection. Furthermore, unresolving abscesses should suggest the need for early re-imaging rather than simple surgical re-exploration. Prognosis in this case was favourable due to early drainage of the abscess and aggressive antibiotic treatment prior to the CT, followed
Images for surgeons
by early drainage of the mediastinal abscess. This facilitated the use of a minimally invasive strategy of local drainage rather than the need for a radical thoracotomy approach. Antimicrobial therapy in conjunction with surgical debridement decreases mortality risk by 40%.8 In summary, this is the first documented case of an acupuncture event leading to mediastinal abscess formation. Clinicians and patients need to be aware of some of the potential risks of acupuncture, particularly infection. In addition, the possibility of deep tracking should be considered in unresolving, but seemingly benign abscess. With early clinician awareness and diagnosis, the potentially catastrophic complications of mediastinal abscesses can be treated successfully with minimally invasive techniques.
References 1. Xu QY, Yin GW, Chen X, Jiang F, Bai XJ, Wu JD. Fluoroscopically guided nose tube drainage of mediastinal abscesses in post-operative gastro-oesophageal anastomotic leakage. Br. J. Radiol. 2012; 85: 1477– 81. 2. Mandell GL, Bennett JE, Dolin R. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases, 7th edn. Philadelphia: Churchill Livingstone, 2010; 1173–82. Chapter 82. 3. Kouritas VK, Zissis C, Bellenis I. Staphylococcal isolated anterosuperior mediastinal abscess of unknown origin. Interact. Cardiovasc. Thorac. Surg. 2012; 14: 650–1. 4. Zhang J, Shang H, Gao X, Ernst E. Acupuncture-related adverse events: a systematic review of the Chinese literature. Bull. World Health Organ. 2010; 88: 915–21. 5. Xu S, Wang L, Cooper E et al. Adverse events of acupuncture: a systematic review of case reports. Evid. Based Complement. Alternat. Med. 2013; 2013: 581203. 6. Murray RJ1, Pearson JC, Coombs GW et al. Outbreak of invasive methicillin-resistant Staphylococcus aureus infection associated with acupuncture and joint injection. Infect. Control Hosp. Epidemiol. 2008; 29: 859–65. 7. Kang SK, Lee S, Oh HK et al. Clinical features of deep neck infections and predisposing factors for mediastinal extension. Korean J. Thorac. Cardiovasc. Surg. 2012; 45: 171–6. 8. Karra R, McDermott L, Connelly S et al. Risk factors for 1-year mortality after postoperative mediastinitis. J. Thorac. Cardiovasc. Surg. 2006; 132: 537–43.
Luke Traeger,* MBBS Marrillo Jayasuriya,† BSc, MBBS Aravind Suppiah,† MD, FRCS Peter G. Devitt,*† MS, FRACS *School of Medicine, University of Adelaide, Adelaide, South Australia, Australia and †Discipline of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia doi: 10.1111/ans.13010
© 2015 Royal Australasian College of Surgeons
