Chronic Mediastinitis Research Articles

Immuungemedieerde hemolytische anemie geassocieerd met chronisch fibroserende mediastinitis bij een Arabo-Fries paard

In deze casuïstiek wordt een tienjarige ruin beschreven met immuungemedieerde hemolytische anemie geassocieerd met chronische fibroserende mediastinitis van onbekende oorsprong. De patiënt leed aan chronisch gewichtsverlies en intermitterende diarree en werd aangeboden in de kliniek met uitgesproken anemie, anorexie en koorts die reeds 24 uur aanwezig was. Een directe Coombs’ test was sterk positief voor IgG-autoagglutinatie. Bij het klinisch onderzoek werd geen onderliggend patho-logisch proces van de immuungemedieerde hemolytische anemie gevonden. Post-mortemonderzoek toonde groene vloeistof met voedselpartikels in het craniale mediastinum aan. Histologisch onderzoek suggereerde chronische fibroserende mediastinitis. Hoewel slokdarmperforatie hiervoor een mogelijke oorzaak is, werden bij macroscopisch onderzoek geen tekenen van ruptuur waargenomen. In deze casereport wordt aangetoond dat bij niet-responsieve, immuungemedieerde hemolytische anemie, een niet-gedetecteerde onderliggende pathologie, zoals chronische mediastinitis, aanwezig kan zijn.

Therapeutic alternatives after aborted sternotomy at the time of surgical aortic valve replacement in the TAVI Era—Five centre experience and systematic review

BackgroundWe aimed to analyze causes, management, and outcomes of the unexpected need to abort sternotomy in aortic stenosis (AS) patients accepted for surgical aortic valve replacement (SAVR) in the transcatheter aortic valve implantation (TAVI) era. MethodsCases of aborted sternotomy (AbS) were gathered from 5 centers between 2009 and 2014. A systematic review of all published cases in the same period was performed. ResultsA total of 31 patients (71% males, 74±8years, LogEuroSCORE 11.9±7.4%) suffered an AbS (0.19% of all sternotomies). Main reasons for Abs included previously unknown porcelain aorta (PAo) in 83.9%, mediastinal fibrosis due to radiotherapy in 12.9%, and chronic mediastinitis in 3.2%. Median time between AbS and next intervention was 2.3months (IQR: 0.7–5.8) with no mortality within this period. Only a case was managed with open surgery. In 30 patients (96.8%) TAVI was performed with a rate of success of 86.7%. Three patients (9.7%) presented in-hospital death and 17 (54.8%) had in-hospital complications including heart failure (9.6%), major bleeding (6.9%), and acute kidney injury (9.6%). Older patients (76±8 vs. 70±8years, p=0.045), previous cardiac surgery (60% vs. 15.4%, p=0.029), and shorter time from AbS to next intervention (5.1±5 vs. 1±0.7months, p=0.001) were related to higher six-month mortality (22.6%). ConclusionsThe main reason for AbS was PAo. This entity was associated to a higher rate of complications and mortality, especially in older patients and with prior cardiac surgery. A preventive strategy in these subgroups might be based on imaging evaluation. TAVI was the most extended therapy.

Treatment of chronic mediastinitis

Chronic mediastinitis is a rare disorder characterized by the proliferation of fibrous tissue within the mediastinum resulting in compression of mediastinal structures. This article gives an overview of the treatment options for chronic mediastinitis. A literature search was carried out regarding treatment options for chronic mediastinitis Little is known about the pathogenesis of chronic mediastinitis, which has hampered the development of novel therapeutic approaches. There is no convincing evidence for the success of medicinal (antifungal or conventional anti-inflammatory) therapy and it is not recommended. In cases of clinical symptoms procedures for decompression, such as endovascular or endobronchial stents or surgical procedures, such as decompression interventions or extra-anatomic bypasses should be considered. The prognosis for unilateral involvement is better than for bilateral involvement if performed in specialized centers.

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.

Descending Necrotizing Mediastinitis of Odontogenic Origin in a Young Male Patient: Case Report and Discussion

Background: Mediastinitis is an inflammatory process that can be presented acute or chronic. Acute mediastinitis occurs secondary due to esophagus perforation or induced by infections of odontogenic or retrapharyngealorigins. The most common form is the postsurgical mediastinitis after cardiovascular interventions. Descending necrotizing mediastinitis and acute infectious mediastinitis has often a fulminate and fatal course. Chronic mediastinitis (or sclerosing fibrosing mediastinitis) appears to be associated with long standing mediastinitis, which induces collagenous and fibrous overgrowth. Case Report: Forty-one year-old male patient without significant past medical history presented with 2-weeks history of progressive shortness of breath, productive cough, generalized dental pain and, facial swelling. In the further workup he was found to have an acute odontogenic mediastinitis complicated by deep neck abscess after recent history of dental extraction. Hospital course included respiratory failure induced by sepsis and possible airway compression from the deep neck abscess. He was intubated, placed on mechanical ventilation, and required multiple surgical interventions including but not limited to drainage, chest tubes, and thoracentesis. Intravenous antibiotic treatment with Metronidazole and Ceftriaxone was initiated. After long-standing treatment his condition improved and was discharged home. Conclusion: Odonotogenic mediastinitis with deep neck abscess should be considered in patients with recent tooth aches/infection or dental surgery. Early recognition, surgical, and antimicrobial treatment are implemented with good prognosis and outcome.

Diagnostic Algorithm in Patients with Superior Vena Cava Syndrome and Efficacy of Cervical Mediastinoscopy

Background: Superior vena cava syndrome (SVCS) is the result of the direct obstruction of the superior vena cava by malignancy and/or mediastinal lymphadenopathy. Our aim is to propose a diagnostic algorithm for undiagnosed superior vena cava syndrome patients and compare the diagnostic value, mortality and morbidity rates in patients diagnosed by mediastinoscopy.Methods: Ninety-seven patients with SVCS underwent diagnostic management starting with the least invasive technique and proceeding to more advanced and invasive methods between January 2000 and June 2013. Seventy one (73%) patients received histopathologic diagnosis using local biopsy, endobronchial biopsy by fiberoptic bronchoscopy and/or endobronchial ultrasound (EBUS) and CT-guided fine needle aspiration biopsy. Twenty six patients out of 97 patients who had superior vena cava syndrome underwent cervical mediastinoscopy for definitive diagnosis. Four patients (three male and one female) received histopathologic diagnosis using EBUS with the use of this method in our institution after 2010.Results: Of 26 patients who underwent cervical mediastinoscopy, 11 had small cell lung carcinoma, six had squamous cell lung carcinoma, three had adenocarcinoma, two had lymphoma, one had thymoma, one had tuberculosis, one had seminoma and one had chronic fibrous mediastinitis. Definitive tissue diagnosis was obtained in all patients. No peri-operative mortality was recorded. One patient had minor bleeding which was controlled without additional surgical intervention.Conclusions: We propose a diagnostic algorithm in undiagnosed patients with superior vena cava syndrome. We conclude that cervical mediastinoscopy is a safe, fast and effective technique to establish pathologic diagnosis, and directs the physicians to apply the appropriate treatment in clinically diagnosed superior vena cava syndrome when less invasive techniques have been unsuccessful.

Sténose œsophagienne non-néoplasique: pas toujours si bénigne

Esophageal intramural pseudodiverticulosis is a rare pathology whose etiology is unknown, but which is frequently associated with three highly prevalent entities: esophageal reflux disease, esophageal candidosis and alcoholic esophagitis. With conservative treatment the course of these pathologies is usually benign. However, some severe cases are resistant to conservative treatment and may require more aggressive management. We here present the case of patient suffering from a severe esophagitis complicated by chronic mediastinitis with life-threatening repercussions, requiring esophagectomy as treatment.

A rare pulmonary zygomycosis manifested as chronic mediastinitis and bronchial perforation

To the Editors: Zygomycosis is an emerging infection caused by fungi of class Zygomycetes, order Mucorales. It occurs mostly in diabetic and immunocompromised patients, but occasionally occurs in immunocompetent individuals [1]. After rhinocerebral zygomycosis, pulmonary zygomycosis, which carries a high mortality rate, is the second most common presentation [1]. Common manifestations of pulmonary zygomycosis mainly include different types of pulmonary infiltrates [2], and other rare manifestations such as endobronchial mass lesions or mediastinitis. However, in the literature, bronchial perforation caused by zygomycetes has not been previously documented. This report presents the case of a diabetic patient infected with Rhizopus sp., which resulted in chronic mediastinitis and bronchial perforation. A 76-yr-old, Chinese, never-smoking female with uncontrolled type 2 diabetes experienced a productive cough for 6 months prior to admission. This patient denied having fever, breathlessness, night sweating or body weight loss. Physical examination revealed a moderately nourished female without respiratory distress or fever. Upon admission, laboratory studies revealed a haemoglobin level of 10.5 g·dL−1, white blood cell count 5.4×103 cells per μL (53.3% neutrophils, 28.3% lymphocytes, 6% monocytes and 12% eosinophils), platelet count 355×103 cells per μL, creatinine 0.9 mg·dL−1, C-reactive protein 1.7 mg·dL−1, fasting glucose level 311 mg·dL−1 and glycated haemoglobin 14.7%. The chest radiograph on admission revealed partial atelectasis of the …

An Unusual Case of Aspergillus Fibrosing Mediastinitis

Fibrosing mediastinitis due to Aspergillus is rare, particularly in the immunocompetent host. Fibrosing mediastinitis due to Aspergillus species in the immunocompetent patient can be indolent and may be treated with antifungal therapy rather than surgery. We present a 78-year-old nonsmoking, nondiabetic woman with chronic fibrosing mediastinitis due to Aspergillus. Multiple attempts at securing a tissue diagnosis were inconclusive. Ultimately, Aspergillus infection was diagnosed by a video-assisted thoracoscopic surgical biopsy. The patient was started on oral voriconazole, and she remains clinically stable with radiographic improvement. A prolonged, perhaps lifelong, course of antifungal therapy is planned.

Does wrapping of the right internal thoracic artery to the left anterior descending artery always protect?

We report about a 72-year-old woman with coronary artery disease. Surgical revascularization was performed using three grafts. One of them was the right internal thoracic artery (RITA) to left anterior descending. This graft was covered by a PRECLUDE IMA Sleeve. Wound healing was impaired and became to a chronic sternal osteomyelitis and mediastinitis. Thirty-three months after the primary operation, the PRECLUDE IMA Sleeve was explanted, the sternum was partially resected and the resulting cavity reconstructed with an omentum flap. During that operation, the RITA bypass was damaged. Interposition of a venous segment was necessary to reconstitute the graft.

Caustic damage of the gastrointestinal tract: roentgen features.

CAUSTIC DAMAGE OF THE GASTROINTESTINAL TRACT: ROENTGEN FEATURESE. A. FRANKEN, JR., M.D.Audio Available | Share

Unilateral Pulmonary Arteriosclerosis

An extensive fibrous connective tissue proliferation suggestive of retroperitoneal fibrosis or chronic mediastinitis is reported here. Aside from being the most extensive involvement that we can find after reviewing the literature, this lesion produced a most interesting natural experiment in the development of pulmonary arteriosclerosis. This change was unilateral and associated with complete obstruction of the pulmonary vein on the involved side. Although there have been several case reports of pulmonary vein obstruction in association with a similar lesion, none of these has been unilateral and unaccompanied by cor pulmonale. Report of Case His first admission was in 1951, at age 39, because of a history of hemoptysis which was of 9 years' duration. In 1942 he had gone to Arizona for several months following a period of heavy cough, mild hemoptysis, fever, and weight loss from which he made an uneventful recovery. Chest x-rays at that time are said

Spontaneous paralysis of the phrenic nerve with a special reference to chronic pulmonary tuberculosis

Eight cases of paralysis of phrenic nerves are described. All these patients had been suffering from chronic pulmonary tuberculosis. The possible mechanism of this association is discussed and special stress is laid on post-inflammatory fibrosis and chronic mediastinitis. One of the cases described had recurrent laryngeal nerve palsy in addition to ipsilateral hemi-diaphragmatic paralysis. The literature is reviewed.

Spontaneous laryngeal paralysis in chronic pulmonary tuberculosis

Five cases of paralysis of the left recurrent laryngeal nerve are described. All these patients had chronic pulmonary tuberculosis. The possible mechanisms of this association are discussed and special stress is laid on chronic mediastinitis. The literature is reviewed and it is suggested that this syndrome may be much commoner than hitherto believed.

Chronic Fibrous Mediastinitis and Superior Vena Caval Obstruction Due to Histoplasmosis

SUMMARY Four patients, age 25 to 30 years, with bronchial or mediastinal venous obstruction due to chronic fibrous mediastinitis are reported. Fibrous mediastinal lesions with various degrees of calcification were so extensive, obliterating anatomical planes, that pulmonary resections were technically impossible or considered unwise. Clinical and laboratory findings with uniform gross and microscopic appearance of these intrathoracic lesions, in our opinion, has given us a sufficient basis to make a diagnosis of chronic fibrous mediastinitis due to histoplasmosis. Morphologically typical organisms of histoplasma capsulatum were demonstrated in the caseous material from a granulomatous lymph node in one patient and organisms highly suggestive of such a fungus disease were found in another. Multiple mediastinal biopsies from the other two patients were not conclusively diagnostic in that no lymph node demonstrating such early collagenous replacement of necrotic foci was encountered although the typical hyalinized fibrous and calcific tissue was in abundance. Discussion points are presented dispelling the past opinions that severe chronic mediastinitis and associated superior vena caval obstruction may be the result of a tuberculous process.

SURGICAL REVERSAL OF SUPERIOR VENA CAVA SYNDROME

SINCE William Hunter, in 1757, described a case of obstruction of the superior vena cava, many other cases have been reported in the world literature. Although the syndrome produced by such obstruction is relatively constant, the obstruction itself may result from many different primary diseases. Ehrlich, Ballon, and Graham1reviewed the world literature to 1933 on this subject and reported 309 cases. In their series, the etiologic agent in 35% of cases was aortic aneurysm, with or without arteriovenous fistula; in 50%, thoracic neoplasms, primary and secondary, and in 15%, rarer causes. In 1949, McIntire and Sykes2reviewed 219 cases and found the etiologic factor to be aortic aneurysm in 26.9%, primary and secondary thoracic neoplasms in 33%, chronic mediastinitis in 20.7%, and miscellaneous factors in 19.4%. Glushien and Mansuy3as well as Rose4have stressed the poor prognosis in vena caval obstructions, and the former

Chronic tuberculous mediastinitis and mediastinal lymphadenitis; report of two cases illustrating certain complications with surgical measures for their relief.

Chronic tuberculous mediastinitis and mediastinal lymphadenitis; report of two cases illustrating certain complications with surgical measures for their relief.

Complete Occlusion of the Superior Vena Cava with Chronic Mediastinitis in a Case of Generalized Actinomycosis

Complete Occlusion of the Superior Vena Cava with Chronic Mediastinitis in a Case of Generalized Actinomycosis

Diseases of the Mediastinum and Associated Conditions

This Discussion includes those diseases and conditions which may produce abnormal shadows in and adjacent to the mediastinum. Cardiac and vascular lesions are not included except where they need to be differentiated from other mediastinal masses. Those diseases in which the major roentgenological manifestations are in the pulmonary parenchyma are discussed briefly, if at all, since the roentgen diagnosis is based more on the pulmonary changes than on mediastinal variations. As with other regions of the body, it is possible to classify mediastinal lesions in various ways. The classification given below is based on the anatomical structures contained within the mediastinum and has the advantage of relative simplicity. Also it is essential in the differential diagnosis to determine, first of all, the anatomical division of the mediastinum involved and, second, if possible, the structure or structures which may have given rise to the abnormality in question. Once this has been accomplished, the diagnostic possibilities become limited. I. Diseases of the mediastinal lymph nodes Infections Non-specific lymphadenopathy Acute and chronic Fungus infections Tuberculosis Primary tuberculosis Hyperplastic tuberculosis Associated with caseous tuberculosis Associated with erythema nodosum Boeck's sarcoid Asymptomatic form Tumors of the mediastinal lymph nodes Primary malignant Hodgkin's disease, lymphosarcoma, leukemia, aleukemic leukemia Metastatic tumors II. Primary tumors of mediastinum other than lymph node tumors Benign Lipoma, fibroma, dermoid cyst and teratoma, chondroma, ganglioneuroma, neurofibroma, cystic hygroma Malignant Fibrosarcoma, neurofibrosarcoma, liposarcoma, thymoma III. Mediastinitis Acute mediastinitis Acute diffuse mediastinitis Acute mediastinal abscess Chronic mediastinitis Chronic mediastinal abscess Chronic diffuse or fibrous mediastinitis Mediastinopleural (paramediastinal) effusion Mediastinal emphysema IV. Diseases of the thyroid and thymus Thymic hyperplasia in children Thymic tumors Enlarged thyroid, substernal thyroid and intrathoracic goiter V. Diseases of the spine Tuberculosis and other infections Tumors VI. Cardiovascular lesions Enlarged left auricle Aneurysm of aorta Right-sided aorta Pulmonary artery dilatation Aneurysm of innominate artery VII. Diseases of esophagus and stomach Cardiospasm Esophageal hiatus hernia and thoracic stomach VIII. Bronchogenic carcinoma Anatomy Of The Mediastinum The mediastinum is defined as that space lying between the right and left pleurae, in and near the median sagittal plane of the chest (Fig. 1). It extends from the sternum in front to the vertebral column behind and contains all the thoracic viscera except the lungs. For convenience in description anatomists usually divide it into four parts, the superior, anterior, middle, and posterior spaces (4).

Recognition and management of mediastinitis

LTHOUGH chronic mediastinitis is a A rare disease, acute mediastinitis is not nearly so infrequent as the profession once beIieved. Numerous reports in the past few years indicate the fairly common occurrence of acute infections of the cervica1 and thoracic mediastinum. When one considers the ease of access to the fascial pIane& for spontaneous infections of the mouth, nose and throat, cervicaI Iymph-nodes, neopIasms of the pharynx and esophagus, and foreign bodies, it is fortunate that nature is so kind in building inff ammatory barriers to prevent the downward extension of many of these infections. An accurate concept of the practica1 anatomy of these fascial pIanes of the neck and thorax, as so vividIy described by Furstenberg and YgIesias, demonstrates the continuity of the retroviscera1 space as a compartment (Figs. I and 2) bounded behind by the prevertebra1 Iayer of cervica1 fascia, in front by the pharynx and esophagus and the IateraI extension of the retroesophageal fascia, which is a derivative of the pretrachea1 Iayer, and IateraIIy by the carotid sheaths. It extends from the base of the skuII to the diaphragm. This makes easy migration of infection from the retropharyngea1 or retroesophagea1 Iocations into the posterior thoracic mediastinum, and it is remarkabIe that inffammatory barriers so frequentIy IocaIize the infection to the cervica1 portion. Surrounding the viscera of the neck consisting of the pharynx and esophagus behind and trachea and thyroid in front, is a cyIindrica1 sheath. This consists of the pretrachea1 Iayer which extends IateraIIy to join the prevertebra1 Iayer at the carotid sheath and is continued posteriorIy as the retropharyngea1 or buccopharyngea1 fascia above and the retroesophagea1 fascia beIow, constituting the vascuIoviscera1 fascia. This bIends with the aorta as the arch crosses the trachea and encIoses the descending Iimb. It continues downward to fuse with the pericardium at about the IeveI of the bifurcation of the trachea at the sixth thoracic vertebra. Thus the other practica1 mediastina1 space, the anterior or viscera1 space, extends from pharynx and Iarynx above to the bifurcation of the trachea beIow. The potentia1 space immediateIy behind the sternum, incIuded in anatomy textbooks as a part of the anterior mediastinum, is protected from the spread of cervica1 infections by the junction of the superficial Iayer of cervica1 fascia and its muscuIar investments, with the posterior surface of the manubrium sterni so that infections reach this space onIy when they originate from injury or infection of the anterior chest waI1 at the IeveI of the first and second Costa1 cartiIages. In the vascuIoviscera1 fascia1 compartment Iie many Iymph-nodes and vesseIs, and it is into this space that nose, throat and ear infections frequentIy trave1. On the other hand, perforations of the posterior pharyngea1 or esophagea1 waIIs by foreign bodies usuaIIy invoIve the retroviscera1 space and are more prone to extend deep into the thorax. One or both of these spaces may be impIicated and the intimate reIationship to the pIeurae and pericardium Ieads to infection of these at times. PracticaIIy, then, there are two main spaces, the retroviscera1 and the vascuIoviscera1, which may be infected and are continuous from neck to thorax with onIy theoretica1, but no actua1 division between the cervica1 and thoracic portions. The concept that the mediastinum extends from the base of the skuI1 to the diaphragm is a good one for practica1 purposes. The extent to which infection of these spaces may spread is influenced by the