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Images in emergency medicine
Cervical necrotising fasciitis with descending mediastinitis An elderly woman presented with fever, sore throat, difficulty swallowing and substernal chest pain that radiated to her shoulder for 3 days. She was febrile (38.8° C), tachycardic (133 bpm), and hypotensive (85/54 mmHg). Physical exams revealed neck tenderness without lymphadenopathy and bulging of left pharyngeal wall. Laboratory exams revealed elevated both white blood cell count (19.25 K/ μL) and C-reactive protein (16.19 mg/dL). Lateral X-ray of neck (figure 1) showed thickening of retropharyngeal soft tissue (arrow) and abnormal air accumulation in the anterior neck (arrowhead). A subsequent contrast-enhanced CT (figures 2–4) confirmed the diagnosis of cervical necrotising fasciitis with descending necrotising mediastinitis. She received intravenous antibiotic treatment, transcervical incision and drainage, and urgent debridement by thoracoscopic approach. However, she died of severe sepsis at postoperative day 4. Descending necrotising mediastinitis is a potentially lethal disease caused by downward spread of deep neck infection. The infection may be originated from pharyngeal or odontogenic infections. Despite the modern antibiotic treatment and surgical technique, it still being reported with a mortality rate of 15% in recent meta-analysis.1 Along with thorough history taking and physical exams, contrast-enhanced CT image
Figure 1 Lateral X-ray of the patient’s neck showed thickening of retropharyngeal soft tissue (arrow) and abnormal air accumulation in the anterior neck (arrowhead).
Figure 3
Abnormal gas in the bilateral neck and upper anterior mediastinum.
Figure 4
Pericardial effusions and left pleural effusions.
was valuable for establishing the diagnosis. Prompt diagnosis with antibiotic treatment and urgent surgical intervention are crucial to improve survival.
Chih-Yang Hsiao, Abel Po-Hao Huang Department of Surgery, National Taiwan University Hospital, Taipei City, Taiwan Correspondence to Dr Abel Po-Hao Huang, Department of Surgery, National Taiwan University Hospital, No.7, Zhongshan S. Rd., Zhongzheng District, Taipei City 100, Taiwan; [email protected] Contributors CYH and APHH were responsible for the drafting of the manuscript. CYH conducted a survey and submitted the study. Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed.
To cite Hsiao C-Y, Huang AP-H. Emerg Med J 2015;32:339. Received 24 October 2013 Revised 4 November 2013 Accepted 13 November 2013 Published Online First 6 December 2013 Emerg Med J 2015;32:339. doi:10.1136/emermed-2013-203313
REFERENCE Figure 2
Contrast-enhanced CT of the neck and chest showed much fluid collection at the left peritonsillar region, with extension into the parapharyngeal spaces.
1
Ridder GJ, Maier W, Kinzer S, et al. Descending necrotizing mediastinitis: contemporary trends in etiology, diagnosis, management, and outcome. Ann Surg 2010;251:528.
Hsiao C-Y, et al. Emerg Med J April 2015 Vol 32 No 4
339
Downloaded from http://emj.bmj.com/ on September 20, 2015 - Published by group.bmj.com
Cervical necrotising fasciitis with descending mediastinitis Chih-Yang Hsiao and Abel Po-Hao Huang Emerg Med J 2015 32: 339 originally published online December 6, 2013
doi: 10.1136/emermed-2013-203313 Updated information and services can be found at: http://emj.bmj.com/content/32/4/339
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Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Images in emergency medicine
Cervical necrotising fasciitis with descending mediastinitis An elderly woman presented with fever, sore throat, difficulty swallowing and substernal chest pain that radiated to her shoulder for 3 days. She was febrile (38.8° C), tachycardic (133 bpm), and hypotensive (85/54 mmHg). Physical exams revealed neck tenderness without lymphadenopathy and bulging of left pharyngeal wall. Laboratory exams revealed elevated both white blood cell count (19.25 K/ μL) and C-reactive protein (16.19 mg/dL). Lateral X-ray of neck (figure 1) showed thickening of retropharyngeal soft tissue (arrow) and abnormal air accumulation in the anterior neck (arrowhead). A subsequent contrast-enhanced CT (figures 2–4) confirmed the diagnosis of cervical necrotising fasciitis with descending necrotising mediastinitis. She received intravenous antibiotic treatment, transcervical incision and drainage, and urgent debridement by thoracoscopic approach. However, she died of severe sepsis at postoperative day 4. Descending necrotising mediastinitis is a potentially lethal disease caused by downward spread of deep neck infection. The infection may be originated from pharyngeal or odontogenic infections. Despite the modern antibiotic treatment and surgical technique, it still being reported with a mortality rate of 15% in recent meta-analysis.1 Along with thorough history taking and physical exams, contrast-enhanced CT image
Figure 1 Lateral X-ray of the patient’s neck showed thickening of retropharyngeal soft tissue (arrow) and abnormal air accumulation in the anterior neck (arrowhead).
Figure 3
Abnormal gas in the bilateral neck and upper anterior mediastinum.
Figure 4
Pericardial effusions and left pleural effusions.
was valuable for establishing the diagnosis. Prompt diagnosis with antibiotic treatment and urgent surgical intervention are crucial to improve survival.
Chih-Yang Hsiao, Abel Po-Hao Huang Department of Surgery, National Taiwan University Hospital, Taipei City, Taiwan Correspondence to Dr Abel Po-Hao Huang, Department of Surgery, National Taiwan University Hospital, No.7, Zhongshan S. Rd., Zhongzheng District, Taipei City 100, Taiwan; [email protected] Contributors CYH and APHH were responsible for the drafting of the manuscript. CYH conducted a survey and submitted the study. Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed.
To cite Hsiao C-Y, Huang AP-H. Emerg Med J 2015;32:339. Received 24 October 2013 Revised 4 November 2013 Accepted 13 November 2013 Published Online First 6 December 2013 Emerg Med J 2015;32:339. doi:10.1136/emermed-2013-203313
REFERENCE Figure 2
Contrast-enhanced CT of the neck and chest showed much fluid collection at the left peritonsillar region, with extension into the parapharyngeal spaces.
1
Ridder GJ, Maier W, Kinzer S, et al. Descending necrotizing mediastinitis: contemporary trends in etiology, diagnosis, management, and outcome. Ann Surg 2010;251:528.
Hsiao C-Y, et al. Emerg Med J April 2015 Vol 32 No 4
339
Downloaded from http://emj.bmj.com/ on September 20, 2015 - Published by group.bmj.com
Cervical necrotising fasciitis with descending mediastinitis Chih-Yang Hsiao and Abel Po-Hao Huang Emerg Med J 2015 32: 339 originally published online December 6, 2013
doi: 10.1136/emermed-2013-203313 Updated information and services can be found at: http://emj.bmj.com/content/32/4/339
These include:
References Email alerting service
Topic Collections
This article cites 1 articles, 0 of which you can access for free at: http://emj.bmj.com/content/32/4/339#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Clinical diagnostic tests (1001) Drugs: infectious diseases (268) Radiology (949) Radiology (diagnostics) (856) Pain (neurology) (957) Ethics (374) Ear, nose and throat/otolaryngology (107) TB and other respiratory infections (150)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
