Mediastinitis: Case
Report and
Implications for
Clinical Practice
Melissa Benbow MD
James Rick MD
What’s the cause of mediastinitis?
• Hint…
• “It ain’t no black swan, just a goose
on the loose.”
HPI
• 8yo F with 1 month of chest pain. Seen by PCP
at onset and had normal exam at that time.
• 2wk prior to admission developed fevers to 103,
seen at CMC and admitted for O2 sats in low
90s and fevers, concern for recurrent pericarditis
although normal echo and CXR normal except
increased peribronchial markings. Discharged
home next day.
• 1wk prior to admission having persistent fevers
and chest pain, + flu at PCP so referred to CMC
for repeat flu testing during H1N1 outbreak.
• Flu negative at CMC, but continued amantidine
and tamiflu as rx by PCP.
• Also started on zithromax for concern at OSH of
pneumonia.
HPI (continued)
• Day of admission was riding bike,
became pale
• Still c/o substernal chest pain
• Won’t lay flat because of difficulty
breathing
• Fevers down since starting
zithromax 99-101
ROS
• Gen: fever, increased fatigue
• HEENT: no significant HA but occasional
mild HA, otherwise negative
• CV: chest pain
• Resp: orthopnea
• GI: no N/V/D/C. Occasional c/o mild
abdominal pain since previous admission
• Neuro: no numbness/tingling. No MS
changes
• MS: occasional c/o knee and ankle pain
but no edema/erythema
PMH
• Pneumonia with parapneumonic
effusions and pericarditis 9/2008
(~8mo prior)
• Was in PICU with pericardial drain
and chest tube
• Thought everything secondary to
pneumonia at that time although no
organism identified
• Had rheumatologic w/u that was
negative
History
• Birth History:
– 38wk c/s secondary to breech
presentation. Home with mom in 3 days.
No complications
• Past Hospitalizations:
– 9-10/2008 for pneumonia, pleural effusion,
pericarditis, in PICU
– Had been healthy prior to that
• Past Surgeries:
– PE tubes, pericardial drain, chest tube
History
• Family History:
– mom with psoriasis
– cousin with JIA
– MGM with ovarian and breast cancer
• Social History:
– lives with mom, 2 half-sisters
– + smoke exposure
– No recent travel
– No pets
– Father h/o incarceration
Physical Exam
• VS: T 38.5, HR 96, RR 28, O2 100% RA, BP 99/61
• Gen: NAD, initially sleeping but arousable and then
alert and cooperative
• HEENT: NCAT, TMs clear b/l, OP clear without
exudate/erythema
• CV: RRR, no m/r/g, 2+ pulses
• Resp: CTAB, no retractions or increased WOB, no
egophony, percussion = b/l
• GI: soft/NT/ND, no HSM/mass, + BS
• MS: FROM x4
• Neuro: CN 2-12 intact
• Skin: warm, dry, no petechiae
Initial Labs
• CBC
• CMP
•
24.4
11.6
35.3
138 97
4.5
508
8
28.7 0.4
74S, 19L, 7M
84
9.8
• Alb 3.2, AP 216, Tbili 0.4, AST 13, ALT 24,
Tprot 8
• ESR 60
• Ferritin 163
• Blood culture pending
Imaging, etc
• CXR…
• Echo: normal
• EKG: normal
CXR
• Cystic lesion with air-fluid levels,
possibly representing
pneumatoceles, in the medial right
lower lobe and possibly medial left
lower lobe. Follow-up is suggested.
Pneumatocele
• Air-filled cysts within lung
parenchyma
• Usually secondary to pneumonia
– Staph
– Strep pneumo
– H. influenzae
• Can be secondary to trauma
CT
CT
CT
CT
CT
CT
CT
Chest CT
• The air collection seen on the plain films is seen as
irregular shaped air collection in the mediastinum
just inferior to the carina. This is not associated
with enhancing mass or fluid collection to suggest
tumor or abscess. This does not appear to
communicate with the pericardium or the esophagus.
Esophagram should be considered as an initial
evaluation to explain the air collection.
• There is one tiny vessel which seen on the inferior
most portion of the scan which extends from the
celiac axis to the top of the liver capsule. A branch
does appear to extend into a tiny area of
consolidation in the right lung base and is
suspicious for sequestration.
• Of note, it was initially read as normal until further
discussion/review of CT and then findings noted
above.
Pulmonary sequestration
• Congenital malformation
• Lung tissue that lacks normal connection
with tracheobronchial tree, therefore is
non-fuctioning
• Receives arterial blood supply from
systemic circulation
• 0.15-6.4% of congenital pulmonary
malformations
Pulmonary sequestration
• 3 types
– Intra-lobar: 75-90% of sequestrations
– Extra-lobar
– Bronchopulmonary-foregut
malformation
Pulmonary sequestration
• Intra-lobar
– Located within a normal lobe
– Lacks its own visceral pleura
– Usually no bronchial connection; if so,
it’s abnormal
– Usually presents in adolescence with
recurrent infection
Pulmonary sequestration
• Extra-lobar
– Located outside a normal lobe
– Has own visceral pleura
– May present as subdiaphragmatic or
retroperitoneal mass
– Usually left-sided
– Presents in infancy with respiratory
compromise
Pulmonary sequestration
• Bronchopulmonary foregut
malformation
– Lung tissue connected to GI tract
– Can be either intra- or extra-lobar
– More common on right side
Case—Pulm and ID consulted
• Differential
– Esophageal/bronchial fistula
– Fistula from previous drains
(pleural/pericardial)
– Pulmonary sequestration--less likely
– Mediastinitis: fibrosing vs postinfectious
– Wegener’s
– Sarcoidosis
– Malignancy
The arthrogram demonstrates smooth extrinsic compression on the
distal esophagus in the area of concern. There is no evidence of
connection between the air pocket seen on the chest x-ray and the
esophagus. The patient was imaged in a right lateral decubitus and
a prone position. ****************************
Impression: There is smooth extrinsic compression on the distal
esophagus but no evidence of a fistula to the air pocket.
Mediastinitis
• Post-op
• Esophageal or tracheal rupture/tear
– Trauma
– Bronch/EGD
– Foreign body
• Oropharyngeal infection (descending
necrotizing mediastinitis)
• TB
• Fibrosing mediastinitis
• Spontaneous
Fibrosing Mediastinitis
• Histoplasma capsulatum
• Ohio and Mississippi Rivers
• Also endemic to areas of the
Caribbean and Central and South
America
• Transmission:
– Soil contaminated with bird droppings
– Bat guano
3 Forms of Histoplasmosis
1. Acute pulmonary infection
– Initial exposure to spores
– Most are asymptomatic
– Children and elderly more likely symptomatic
• Weight loss, fever, fatigue, dyspnea
• 10% have sarcoid-like illness with arthritis/arthralgia,
pericarditis, keratoconjunctivitis, erythema nodosum
• Children often normal CXR but can have hilar
adenopathy, patchy pneumonia
– Complications include mediastinal
granulomas and histoplasmomas
• Histoplasmomas: usually asymptomatic, usually
single lesion, calcified, parenchymal origin
Acute Pulmonary Infection
– Mediastinal granulomas: coalescence of hilar
nodes
• Can compress mediastinal structures: esophagus,
trachea/bronchi, vena cava
• Dysphagia, cough, wheeze, hemoptysis, dyspnea,
chest pain
• Mediastinal fibrosis (fibrosing mediastinitis):
uncontrolled fibrotic reaction
• SVC syndrome, pulmonary venous obstruction,
pulmonary artery obstruction with CHF
– SVC syndrome: dyspnea (63%), cough, chest pain,
orthopnea, dysphagia, HA, venous distention of neck,
facial edema, upper extremity edema, plethora,
cyanosis, papilledema, MS changes
3 Forms of Histoplasmosis
2. Chronic pulmonary histoplasmosis
– Opportunistic infection in adults with
emphysema, rare in children
3. Progressive disseminated histoplasmosis
– Affects children and immuno-compromised
– Fever, hepatosplenomegaly,
thrombocytopenia, anemia, pneumonia
– Extrapulmonary infection: bony lesions,
oropharyngeal ulcers, chorioretinitis,
endocarditis
– Increased LFTs, elevated ACE
Back to the Case
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Histo urine Ag: negative
Histo yeast Ab: negative
Histo mycelial Ab: negative
Blastomyces Ab titer: negative
Coccidiodes Ab titer: negative
Aspergillus Galactomannan antigen
ACE: 28 (normal)
ANCA: normal
PPD: negative
Heme/Onc Consult
• LDH: normal
• Uric acid: normal
• No evidence of malignancy
Case continued
• Pt continued have be febrile on a
daily basis
• Cefuroxime
• Clinda later added
Case continued
• GI Consult
• Plan to do EGD & bronch
• However…
– Transferred to Cincinnati for possible
mediastinoscopy and biopsy
– Outpt EGD/bronch scheduled with
pulm/GI
Case continued
• Lost to f/u at CMC because she was
seen at Cincinnati
• Until…
• Sept, I saw her in ED
– CC: chest pain
– EKG, CXR, troponin normal
Follow-up info
• Never had mediastinoscopy
• She had EGD/bronch in Cincinnati shortly
after transfer
• Had multiple ulcers, one large perforated
esophageal ulcer with fistula that
communicated with mediastinum/lung but
also several gastric ulcers (non-perforated).
• Esophagram showed connection with
mediastinum
• NPO while ulcers healed, NJ feeds
• Carafate, PPI
NOW TO DR. RICK…
References
• Behrman, RE, Kleigman, R & Jenson HB. Nelson’s
Textbook of Pediatrics (16th ed). Philadelphia, PA:
Saunders, Elsevier.
• Bentley, Donald. Pediatric Gastroenterology and Clinical
Nutrition. Lincolnshire, IL: Remedica publishing.
• Oermann,Christopher. June 2, 2008. Bronchopulmonary
sequestration. Retrieved from www.uptodate.com
• Walker, W. Allan. Pediatric Gastrointestinal Disease (4th
ed). Hamilton, Ontario: BC Decker.
• www.cdc.gov