Disorders of the Pleura |

A Pain in the Neck: A 58-Year-Old Female Presents to the ED With a Sore Throat FREE TO VIEW

Patrick Smith, DO; Edward Bridges, MD; Michael Perkins, MD
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National Capital Consortium (Walter Reed) Program, Washington, DC

Chest. 2014;146(4_MeetingAbstracts):470A. doi:10.1378/chest.1994915
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SESSION TITLE: Pleural Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Sore throat is one of the most common complaints encountered in ambulatory medicine. We present an unusual case of sore throat in a healthy female.

CASE PRESENTATION: A 58 year-old female presented to the ED with complaints of sore throat for one week. The patient was found to be tachycardic, febrile, and hypotensive. A chest X-ray (CXR) was without infiltrate, yet had bilateral pleural effusions. She was quickly resuscitated with intravenous fluids, started on broad-spectrum antibiotics, and transferred to the ICU. A thoracentesis of the right pleural space exposed frank puss, and a chest tube was inserted. This pattern was repeated on the left. A rapid smear of the pleural fluid showed Gram-positive cocci. Final cultures would grow Group A Streptococcus (GAS), which also invaded the blood. The patient responded to therapy but developed leukocytosis with no relief of her sore throat. A CT scan of the neck and chest, with contrast, displayed a retropharyngeal abscess with enhancing fluid extending into the mediastinum around the aorta and along the azygoesophageal reflection into the pleural effusions. The patient was diagnosed with descending necrotizing mediastinitis (DNM), and cardiothoracic surgery was consulted for definitive treatment.

DISCUSSION: DNM is a rare disease affecting the connective tissue of the mediastinal organs. Only 18 cases were reported in a single center study over the course of 10 years. DNM occurs when an infection within the deep tissue spaces of the neck spreads into the posterior mediastinum from adjoining fascial planes, the “danger” space being the main offender. It is unlike acute mediastinitis, which most commonly occurs secondary to esophageal perforation and infected sternotomy incisions. In our patient, we believe that the rupture of the mediastinal abscess was responsible for her bilateral empyema, particularly as she had no clinical or radiographic findings suggestive of pneumonia. Nevertheless, the mortality rate of DNM is high, up to 40%, despite antibiotics. Drainage of the infection through surgical intervention is decisive.

CONCLUSIONS: We present a rare case of DNM secondary to a GAS infection of the retropharyngeal space. DNM should be considered in the differential diagnosis of bilateral empyema, especially when there is no evidence of pneumonia.

Reference #1: Chen KC, Chen JS, Kuo SW, et al. Descending necrotizing mediastinitis: a 10-year surgical experience in a single institution. J Thorac Cardiovasc Surg 2008 Jul;136(1):191-8.

DISCLOSURE: The following authors have nothing to disclose: Patrick Smith, Edward Bridges, Michael Perkins

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