Acute Mediastinitis Research Articles

Хірургічне лікування хворих з перфорацією стравоходу, ускладненою гострим гнійним медіастинітом

Мета. Покращити результати лікування хворих з перфорацією стравоходу (ПС), ускладненою гострим гнійним медіастинітом (ГГМ).
 Матеріали і методи. Упродовж 2004 - 2018 рр. у відділенні торакальної хірургії Івано-Франківської обласної клінічної лікарні оперовано 30 хворих з ПС, ускладненою ГГМ. Вік хворих коливався від 21 до 76 років, у середньому становив (36,3 ± 3,9) року. Чоловіків було 21 (70%), жінок - 9 (30%).
 Результати. Інтрамедіастинальне введення антибактеріальних препаратів та зрошення швів стравоходу сприяли швидкій ліквідації гнійно-запального процесу в середостінні. Повністю герметичні шви перфорованої ділянки стравоходу констатували у 6 (37,5%), зменшення розмірів дефекту стінки стравоходу - у 9 (56,2%) із 16 хворих.
 Висновки. ПС слід зашивати для відмежування просвіту стравоходу від клітковини середостіння, локалізації гнійного процесу у середостінні і стабілізації загального стану хворого. Мініінвазивні оперативні втручання за допомогою відеоасистованої торакоскопії можуть слугувати операціями вибору у хворих з ПС та поширеним ГГМ для санації і дренування гнійно-запальних вогнищ у середостінні, стабілізації стану хворих та попередження розвитку септичних ускладнень. Інтрамедіастинальне введення антибактеріальних препаратів та зрошення швів стравоходу дають змогу покращити результати лікування, знизити ендогенну інтоксикацію (ІЕ), прискорити загоєння ПС та ліквідувати гнійний процес у середостінні.

Video-assisted thoracoscopy in the treatment of patients with acute purulent mediastinitis

Treatment of patients with acute purulent mediastinitis (APM) is one of the most complex problems of modern surgery. Mortality in patients with APM can reach 17–80%. The aim of the work was to improve the results of treatment of patients with acute purulent mediastinitis using video-assisted thoracoscopy (VATS). During 2000–2018, 87 patients with APM were treated at the thoracic department of the Ivano-Frankivsk Regional Clinical Hospital. The main methods of surgical treatment in primary APM were lateral thoracotomy, mediastinotomy, suturing of the perforation opening of the esophagus with active drainage of the mediastinum and pleural cavity. The VATS with perforations of the esophagus (EP) with APM was applied in 9 (29.1%) patients and with secondary APM in 8 (13.8%) patients. The advantages of the VATS are minimal operational trauma, reducing the time of operation. According to the diagnosis of the EP, complicated APM, the minimally invasive surgical intervention in some cases can provide sufficient radicalism of intervention with minimal traumatism. The purpose of the VATS should be considered sanation and drainage of paraoesophageal fiber and fiber mediastinum. Thus, the choice of the method of surgical treatment of patients with acute purulent mediastinitis should be strictly individual in each case. Video-assisted thoracoscopy is a method of choice in surgical treatment of patients with acute purulent mediastinitis, which is a little traumatic method, provides a good visualization of all mediastinal units, allows for adequate detection and drainage of affected areas. Prospects for further research — improvement of methods of surgical treatment of patients with APM using the method of the VATS.

Intentional Ingestion of Hydrogen Peroxide

Introduction: Hydrogen peroxide poisoning can cause death. The chemical reactions in the body will produce complications, such as stroke, perforation of the gut, and embolism. These complications are most likely seen with high concentrations. Case Presentation: The patient was a 55-year-old female, who tried to commit suicide by ingestion of approximately 150 cc of hydrogen peroxide. She was brought to the emergency room for medical treatment. During the physical examination, the patient had air in the neck and mediastinum, which is a strong indication of acute mediastinitis. The patient was treated with esophagectomy and feeding jejunostomy. The pathology reported first degree burns of the esophagus without perforation. The patient underwent reconstructive surgery and treatment for eight weeks, yet she died during surgery as a result of low ejection fraction (EF). Conclusions: In this case, the patient intentionally ingested a low concentration (15%) of hydrogen peroxide and as a result experienced first degree burns in the esophagus. The patient did not require surgery for treatment. The presence of white mucus and air around the esophagus and stomach was thought to be indicative of acute mediastinitis and mistakenly exposed the patient to major surgery.

Acute descending necrotizing mediastinitis: four years of experience at a hospital center in Madagascar.

Acute mediastinitis, also called descending necrotizing mediastinitis and cervicomediastinal necrotizing fasciitis, is a disease due to the spread of severe cervical or oropharyngeal infection. Our retrospective study examined clinical records of patients admitted to the surgical intensive care unit for the management of acute mediastinitis during the four-year period 2009-2012. The records showed 14 cases admitted during these four years. The patients' mean age was 30years and 8months, and the M/F sex-ratio was 1.33. The main predisposing factors found were the presence of a severe cervical infection, such as fasciitis, of odontogenic origin or the administration of anti-inflammatory drugs. The diagnosis is based on clinical data findings of thoracic pain with dyspnea or orthopnea, fever, or even septic shock and is confirmed by radiologic findings. The patient's multidisciplinary management combines medical management (supportive medical care in an intensive care unit and broad-spectrum antibiotic therapy) and surgical treatment by bilateral cervicotomy with mediastinal drainage. The mortality rate was high at 71.42%. In Madagascar, neglect of dental health can cause odontogenic fasciitis, which plays an important role in descending mediastinitis, a disease that still has a catastrophic prognosis today.

New Device for Endoscopic Vacuum-Assisted Closure (E-Vac) in Acute Mediastinitis from Esophageal Perforation

Acute mediastinitisis an uncommon but potentially devastating infection involving the structures of the mediastinum. The 2 most common causes of acute mediastinitis are esophageal perforation or median sternotomy. Conventional forms of treatment for acute mediastinitisusually involve surgical revision with open dressings or closed irrigation, or reconstruction with vascularized soft tissue flaps such as omentum or pectoral muscle. Vacuum-assisted closure is a treatment with a wound-healing technique based on the application of local negative pressure to a wound. We present the case of a 73 years old male patient admitted in our clinic with esophageal perforation that appeared possible after a endoscopic dilatation done for a esophageal stenosis in the inferior 1/3 part. Using a modified double-lumen naso-gastrig probe adapted to the negative pressure unit and using the same principle as in the negative pressure treatment of soft tissue wounds we have achieved positive results with successful cure of esophageal perforation. The toraco-abdominal Computer Tomography done with contrast substance confirmed the esophageal perforation, acute mediastinitis and bilateral pleuresia. The patient had a full recovery after 29 days of hospitalization with a positive check-up at one and two months after leaving our clinic.

Septic shock from descending necrotizing mediastinitis \u2013 combined treatment with IgM-enriched immunoglobulin preparation and direct polymyxin B hemoperfusion: a case report

BackgroundDescending necrotizing mediastinitis is a common and progressive polymicrobial infection involving the neck and chest with a high death rate (10 to 40%). From a microbiological point of view, descending necrotizing mediastinitis is sustained by Gram-positive bacteria (43–62%), anaerobes (46–78%), and, rarely, Gram-negative bacteria. Data collected during the Antibiotic Resistance-Istituto Superiore di Sanità project confirmed that Italy is positioned among the countries with the highest levels of resistance in most pathogenic species under surveillance. In particular, 32.9% of Klebsiella pneumoniae isolates were resistant to carbapenem, 33.6% of Staphylococcus aureus to methicillin, and 28.7% and 43.9% of Escherichia coli isolates to third-generation cephalosporins and fluoroquinolones, respectively.Case presentationWe describe the case of a 38-year-old white man with septic shock due to descending necrotizing mediastinitis sustained by multidrug-resistant Gram-negative and Gram-positive bacteria treated after surgery with an IgM-enriched immunoglobulin preparation and polymyxin B hemoperfusion therapy.ConclusionDespite the contrasting data on the use of immunoglobulins and polymyxin B hemoperfusion in septic shock and the lack of literature in cases of acute mediastinitis caused by both Gram-negative and Gram-positive multidrug-resistant bacteria, we obtained an improvement in clinical conditions and the survival of our patient, against all odds.

Mediastinite Aguda: Estudo Retrospetivo de 8 Anos de Abordagem em Cuidados Intensivos

Introdução: A mediastinite aguda é um processo inflamatório dos tecidos que envolvem as estruturas mediastínicas. É uma patologia pouco frequente e com elevada taxa de mortalidade se não for diagnosticada e tratada atempadamente. Realizou-se uma revisão dos casos de mediastinite aguda internados no Serviço de Medicina Intensiva, focando os aspetos demográficos da amostra, etiologia, cuidados prestados e mortalidade associada.Material e Métodos: Análise descritiva retrospetiva da informação constante em processo de todos os doentes internados no Serviço de Medicina Intensiva com o diagnóstico mediastinite, entre 1 de abril de 1996 e 31 de dezembro de 2014.Resultados: A análise incidiu sobre 13 doentes, 54% do género feminino, com média de idade 69 anos. As etiologias obtidas: perfuração do esófago (n=5); mediastinite descendente (n=5); secundária a infeções de outras localizações (n=2); infeção de esternotomia por cirurgia cardíaca (n=1). À admissão no Serviço de Medicina Intensiva 38% encontravam-se em sépsis e 38% em choque séptico. Todos realizaram tomografia computorizada (n=13). Todos foram tratados com antibioterapia, 85% com técnicas cirúrgicas e com 15% técnicas minimamente invasivas. As complicações foram localizadas maioritariamente ao espaço pleural e pulmão (n=7). A mortalidade foi de 15,4%.Conclusão: A nossa série difere do reportado na literatura relativamente aos dados demográficos (mulheres, com idade média superior) e à etiologia das mediastinites (perfuração do esófago e mediastinites descendentes). Para o sucesso do tratamento é fundamental o diagnóstico e abordagem atempada em ambiente de cuidados intensivos pela gravidade, complexidade e multiplicidade das técnicas aplicadas.

Аналіз ускладнень гострого гнійного медіастиніту

Вступ. Гострий гнійний медіастиніт (ГГМ) залишається однією із найбільш тяжких форм загальної хірургічної інфекції. Розвиток ускладнень є одним із вирішальних факторів у перебігу захворювання.
 Матеріали і методи. Впродовж 2000 – 2017 рр. у торакальному відділенні Івано–Франківської обласної клінічної лікарні проходили лікування 65 хворих із ГГМ.
 Результати. Ексудативний плеврит та емпієму плеври виявлено у 76,9%, гнійний бронхіт – у 80%, пневмонію – у 70,7%, ендо– і міокардит – у 59,2%, гостре ураження нирок – у 24,6%, сепсис – у 100% хворих із тотальним і заднім медіастинітом.
 Висновки. Попередження розвитку ускладнень та їх лікування є важливою умовою успішного лікування хворих із ГГМ.

Causes, pathways and diagnostic errors in patients with descending purulent mediastinitis

Background. The high incidence of purulent mediastinitis induces surgeons to find the causes of the development and ways of purulent content spreading from the neck to the mediastinum. Purpose was to determine the most common causes of neck phlegmon, to study the ways of infection spreading into the mediastinal fat, to determine the typology of diagnostic errors and to conduct a mortality analysis, depending on the cause of the disease and the form of acute mediastinitis. Materials and methods. An analysis was performed of the data obtained from 65 patients with neck phlegmon and purulent mediastinitis treated at the thoracic department of the Ivano-Frankivsk Regional Clinical Hospital during 2000–2017. Results. The anterosuperior purulent mediastinitis was diagnosed in 22 (33.8 %), total — in 19 (29.2 %), upper — in 16 (24.6 %), and posterior — in 8 (12.3 %) patients. In 52 % of patients, purulent mediastinitis occurred in case of neck phlegmon localization in the retrovisceral space, in 40.8 % — in the previsceral space. The leading causes of purulent mediastinitis development were tonsilogenic and odontogenic factors, which were established in 80 % of patients. Postoperative lethality in purulent mediastinitis was 26.1 % (17 out of 65 patients died), total purulent mediastinitis was diagnosed in 12 (70.5 %), the upper — in 3 (17.6 %), the posterior — in 2 (11.7 %) of patients. Conclusions. Descending purulent mediastinitis occurred in 52 % of patients with neck phlegmon localization in the retrovisceral space, in 40.8 % of patients — with localization of neck phlegmons in the previsceral space. The leading causes of the descending purulent mediastinitis were odontogenic and tonsilogenic factors found in 71 % of patients. The mortality rate of descending total purulent mediastinitis was 70.5 %.

Mediastinite Descendante Necrosante Aigue: Quatre Annees D’experience Dans Un Centre Hospitalier A Madagascar

Background: The acute mediastinitis also called Descending Necrotizing Mediastinitis or Cervico-mediastinitis necrotizing fasciitis is a disease which is the result of a spread of severe cervical infection down to the mediastinum. Method: A retrospective study was done at the surgical intensive care unit of Joseph Ravoahangy Andrianavalona’s hospital about the management of descending necrotizing mediastinitis from 1 st January 2009 to 31st December 2012. Result: Fourteen cases were reported during four years. The mean age of the patients was 30 years and 8 months, the sex ratio was 1.33. The most common cause found in every cases were severe cervical infections such as fasciitis by dental origin, peritonsillar abcess, sore throat, combined with the administration of non steroid antiinflammatory, of corticoid, of inappropriate antibiotic and also the patients’ health status. The suspicion of diagnosis is made clinically with chest pain associated with dyspnea, fever or septic shock and confirmed by radiologic findings. Conclusion: Nowadays, the mortality rates is high about 71, 42% for our cases. Collaboration of the thoracic surgeons and anesthetists is recommended for an early trancervical drainage of the mediastinitis. In Madagascar, the fasciitis by odontogenic infection is the most common cause of mediastinitis due to the lack of dental care.

Pancreas herniation into the mediastinum: a case report

BackgroundPancreatic tissue found in the mediastinum (both true ectopic and herniated pancreas) is rare. It becomes even more challenging when there are complications associated with this entity.Case presentationWe report an unusual case of pancreatic herniation into the mediastinum in a 90-year-old Caucasian female. This patient initially presented with nausea and vomiting associated with abdominal pain. Serum lipase and amylase both were elevated. Computed tomography scan of the chest, abdomen and pelvis revealed a large hiatal hernia with pancreas herniation into the mediastinum, with superimposed acute pancreatitis likely due to gallstone. Because of its unusual location, the patient also developed acute mediastinitis. The patient was management conservatively and did well. On the day of discharge; she was tolerating a diet, had no pain or nausea and was back to her baseline health.ConclusionAcute pancreatitis can be managed conservatively even if it is in the mediastinum. Also, ectopic or herniated pancreatic tissue is extremely rare and leads to unique clinical presentations, along with diagnostic and therapeutic challenges. Clinicians should not only be vigilant to the presence of ectopic or herniated pancreatic tissue, but also be mindful of the resulting complications.

Early and mid-term results of coronary endarterectomy: Influence of cardiopulmonary bypass and surgical techniques.

Coronary endarterectomy (CE) may be a good option for complete revascularization of diffuse coronary artery diseases, but it has not been widely used because the outcomes have not been definitively identified. This study aims to evaluate the mid-term clinical results of CE and compare the outcomes according to the use of cardiopulmonary bypass (CPB) and the surgical technique used. Between 2004 and 2014, 69 cases of CE were performed in 64 patients. We divided the pa-tients into two groups: 1) on-pump coronary artery bypass with coronary endarterectomy (ONCAB-CE) versus off-pump coronary artery bypass with coronary endarterectomy (OPCAB-CE), and 2) "open" versus "closed" surgical techniques. Operative mortality and major morbidity, were investigated includ-ing perioperative myocardial infarction (PMI), and overall survival. Operative mortality was 4.7% (3/64), and no PMI was observed in the study. No statistical differences in operative mortality rate between the ONCAB-CE and OPCAB-CE groups were found (3.1% vs. 6.2%, p = 1.0) or between open versus closed techniques (6.7% vs. 2.9%, p = 0.6). The incidence of major morbidity including cerebrovascular accident, atrial fibrillation, acute renal failure, mediastinitis, respiratory complications, and bleeding was comparable between all groups. There were seven late mortalities, and no differences were found in overall survival rate between all groups. Coronary endarterectomy appears to be a safe option for patients with diffuse coronary artery disease, regardless of whether CPB or a specified selection of surgical techniques are used.

Surgical Treatment of Acute Mediastinitis Due to Fish Bone

Surgical Treatment of Acute Mediastinitis Due to Fish Bone

Spontaneous Pneumomediastinum From Sustained Valsalva

SESSION TITLE: Student/Resident Case Report Poster - Disorders of the Mediastinum SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: This case discusses the physiology of pneumomediastinum secondary to sustained valsalva and correct management. CASE PRESENTATION: Twenty year old Hispanic male presented for one day history of nausea, fatigue and chest pain. The patient reports daily marijuana use for recreation. The day prior to admission, he smoked 11 grams which initiated several instances of nonbloody and nonbilious vomiting. He reported sharp and retrosternal chest pain not worsened with exertion. A few hours after being admitted, his chest pain and nausea had subsided. X-rays and CT scans showed air within the mediastinum as well as air in the subcutaneous chest wall. The patient did not require subsequent oxygen support or pain control. He was discharged the next day from the hospital with outpatient followup and extensive counseling on drug abuse. DISCUSSION: Repeated Valsalva maneuvers are performed to increase the high during marijuana smoking. The elevated intrathoracic pressure leads to rupture of alveolar membrane causing positive pressure gradient of air from lungs into the mediastinum. In a retrospective study of 500 patients with mediastinal emphysema, 15 patients had repeated Valsalva maneuvers secondary to marijuana use. In all the cases, the patients recovered without further sequelae in two to five days. The differential diagnosis is broad and includes alveolar rupture, tracheobronchial injury, esophageal perforation, head/neck surgery and abdominal injury. Severe asthma, airway obstruction and rib fractures may lead to alveolar rupture. Iatrogenic injury and trauma to trachea, head, neck and abdomen often lead to tracking air down to the mediastinum, The most life threatening cause of pneumomediastinum is secondary to esophageal perforation. Tachycardia is the initial SIRS response within 24 to 48 hours. The Mackler's triad of vomiting, lower chest pain and subcutaneous emphysema may be present. Chest radiograph with water soluble material or a CT scan would be appropriate to identify perforation. Many patients need surgery as irrigation and debridement of mediastinum is required as well as closure of perforation. Percutaneous drainage is often a possibility if it perforation is in the neck and is easilly accessible. CONCLUSIONS: Repeated sustained valsalva often results in pneumothorax and pneumomediastinum. All reported cases in the literature show safe observation for one to two days is adequate if esophageal perforation is not suspected. If esophgeal perforation occurs, tachycardia is often first symptom with SIRS response occuring within 24-48 hours. Emergent surgery and/or percutaneous drainage may be indicated if it is not a contained perforation. Reference #1: Esophageal perforation and Acute Bacterial Mediastinitis: Other Causes of Chest Pain That Can be Easily Missed Cross et al. Medicine (Baltimore) 2015 Reference #2: Pneumomediastinum in heroin and marijuana users Mattox et al. Journal of the American College of Emergency Physicians 1976 DISCLOSURE: The following authors have nothing to disclose: Aritra Sen, Pratik Doshi, Bela Patel No Product/Research Disclosure Information

Concomitant off-pump coronary artery bypass and non-cardiovascular surgery.

Reports on concomitant cardiac and non-cardiovascular surgeries have noted disadvantages in the use of extracorporeal circulation. We assessed the results of concomitant off-pump coronary artery bypass (OPCAB) and non-cardiovascular surgery, and compared them with isolated OPCAB results. Of 2,439 patients who underwent OPCAB between 1999 and 2014, 115 patients underwent concomitant OPCAB and non-cardiovascular surgery. Combined non-cardiovascular diseases included 63 malignant and 52 benign diseases. Concomitant non-cardiovascular surgeries performed were general (n=62), thoracic (n=47), orthopedic (n=3), urologic (n=2) and otolaryngologic surgeries (n=1). Operative results were compared between the OPCAB patients who underwent concomitant non-cardiovascular surgeries (group 1, n=115) and isolated OPCAB patients (group 2, n=2,251). Because preoperative characteristics of the two groups were different, a 1:2 propensity score-matched analysis was performed and operative results of the two matched groups were compared. Operative mortality rates were 0.9% (1/115) in group 1 and 1.0% (22/2,251) in group 2 (P=0.909). Although there were differences in preoperative patient characteristics, postoperative complications, including atrial fibrillation (36.5% vs. 28.8%), perioperative myocardial infarction (MI) (4.3% vs. 5.2%), acute renal failure (1.7% vs. 4.9%), mediastinitis (0.9% vs. 0.8%), bleeding reoperation (0.9% vs. 2.9%), and respiratory complications (2.6% vs. 2.1%), did not show significant differences between the two groups. After a 1:2 propensity score-matched analysis, there were no statistical differences in operative complications between the two groups. Concomitant OPCAB and non-cardiovascular surgeries were not associated with increased mortality and postoperative morbidities when compared with isolated OPCAB.

Acute and chronic mediastinitis

A systematic approach to the etiology and possible course of acute mediastinitis is a prerequisite for adequate diagnostics and therapy. Chronic mediastinitis represents a rarity in the clinical practice. A selective literature search was carried out. An acute infection of the mediastinum occurs after perforation of mediastinal structures, such as the esophagus and trachea mostly of iatrogenic origin and as descending necrotizing mediastinitis (DNM) from oropharyngeal foci. The mortality rate of esophageal injuries, irrespective of the cause is currently given as 12 %. A DNM results from an unobstructed spread along the cervicothoracic spaces and is a severe infection which manifests as a clinical picture of sepsis. The mortality rate given in the currently available literature is 14 %. Chronic mediastinitis is a very rare condition which is characterized by the proliferation of fibrous and collagenous tissue in the mediastinum. Whereas the pathogenesis remains unclear, there are indications for a Histoplasma capsulatum infection as the causal link. The prognosis is good. After perforation of the esophagus or trachea there is always the risk of an infection of the mediastinum; therefore, the diagnosis is followed by further evaluation and early therapy. The DNM can cause unspecific symptoms of sepsis without an obvious focal point. It is important to be aware of a possible correlation between an oropharyngeal center of infection and mediastinitis in order to initiate appropriate diagnostic imaging in cases with the slightest suspicion. Chronic mediastinitis is a rare condition with varying courses and can be difficult to diagnose. An histological clarification for distinction from malignant diseases appears to be a sensible approach.

Surgical treatment of acute mediastinitis

Despite modern intensive care management, acute mediastinitis is still associated with a high morbidity and mortality (up to approximately 40 %). Effective antibiotic therapy, intensive care management, elimination of the causative sources of infection and drainage of the affected mediastinal compartments are the cornerstones of therapy in a multidisciplinary treatment concept. Early diagnosis, prompt and uncompromising initial therapy and planned computed tomography (CT) control after the first stages of therapy in order to decide on the necessity for surgical re-interventions are essential for achieving optimal results. Knowledge of the specific anatomical characteristics is crucial for the understanding of this disease and its treatment; therefore, the current knowledge on fascial layers and interstitial spaces from the neck to the mediastinum is described and discussed. A possible foudroyant spread of the infection, especially within the posterior mediastinum, has to be anticipated. The approach to the mediastinum depends on the mediastinal compartments affected, on the causative disease and on the patient's clinical situation. The surgical approach should be adapted to the particular clinical situation of the individual patient and to the surgical experience of the surgeon. When in doubt, the more invasive approach to the mediastinum, such as bilateral thoracotomy, is recommended. An ascending mediastinitis due to pancreatitis is a very rare condition; however, as chest pains are often the main clinical sign surgeons should be aware of this differential diagnosis. An intraoperative brown-black serous fluid in the mediastinal tissue is virtually pathognomonic. The treatment results of esophageal perforation as the most frequent cause of mediastinitis have been improved by integration of various interventional procedures. Hyperbaric oxygen therapy or immunoglobulin treatment can play an auxiliary role in selected patients with acute mediastinitis.

An interesting case of mediastinitis

Mediastinitis is an inflammatory process; it can be either acute or chronic and it can advance rapidly. Causes of acute mediastinitis usually arise from perforation of the oesophagus or from contiguous spread of neck infections. An important neck or chest pain with fever or the onset of inflammatory index and the enlargement of the mediastinal x-ray image should lead to suspect mediastinitis. The TC-scan of neck and thorax is the gold standard for mediastinitis diagnosis.

Acute Thoracic Findings in Oncologic Patients.

Cancer is the second most common cause of mortality in the United States, with >500,000 deaths reported annually. Acute or emergent findings in this group of patients can be a life-threatening phenomenon that results from malignancy or as a complication of therapy. In many cases, these events can be the first clinical manifestation of malignant disease. Oncologic emergencies have been classified as metabolic, hematologic, and structural emergencies. Within the thorax, most acute oncologic findings involve the lungs and airways in the form of drug toxicity, pulmonary infections, or malignant airway compression; the cardiovascular system in the form of pulmonary embolism, superior vena cava syndrome, cardiac tamponade, or massive hemoptysis; the mediastinum in the form of esophageal perforation, acute mediastinitis, or esophagorespiratory fistula; and the osseous spine and spinal cord in the form of invasion and cord compression. Given the life-threatening nature of many of these disease processes, awareness of such complications is critical to making an accurate diagnosis and formulating appropriate treatment strategies.

Acute Mediastinitis as a Complication of Epstein-Barr Virus

Acute mediastinitis is a rare, potentially life-threatening condition that is most commonly seen as a complication of esophageal perforations or cardiac surgery. The term "descending necrotizing mediastinitis" (DNM) is used to describe oropharyngeal infections that spread to the mediastinum, most commonly following odontogenic infections, peritonsillar or retropharyngeal abscesses, cervical lymphadenitis, trauma, or endotracheal intubation. Infectious mononucleosis is another rare cause of DNM. The mortality of acute mediastinitis is high, while the mortality for DNM is even higher. Major determinants of mortality are delayed diagnosis and/or treatment. While DNM is seen infrequently, its severe nature makes it essential that emergency physicians consider the diagnosis in patients presenting with upper respiratory infections, chest pain, and systemic symptoms, and also in patients with a recent diagnosis of EBV, in order to mitigate a high rate of morbidity and mortality.