Surgical Management of Descending Necrotizing Mediastinitis Complicated by Purulent Pericarditis and Lemierre's Syndrome

Descending necrotizing mediastinitis (DNM) originating from a deep neck infection is rapidly progressive, destructive, and fatal, and it often requires surgical treatment. Despite current advances in antibiotic therapies, diagnostic and surgical techniques, and anesthetic and intensive care protocols, DMN remains a life-threatening condition, with mortality rates of up to 30 per cent. Although there are some reports of the Lemierre’s syndrome (LS) accompanying DNM, to the best of our knowledge, there are no documented reports of LS and purulent pericarditis accompanying DNM. An otherwise healthy 57-year-old man had been experiencing right pharyngeal and right neck pain and swelling since three weeks before admission. Because his symptoms persisted, he consulted his general practitioner for neck lymphadenopathy, who prescribed several kinds of antimicrobial therapy after the diagnosis of pharyngitis. Subsequently, although the cervical swelling subsided, fever and chills appeared five days before admission along with fatigue and anorexia, and he was hospitalized. A previous CT revealed an abscess extending from the right neck to the mediastinum with accompanying air in the pericardium. He was referred to our hospital for further management. The patient was conscious and alert on arrival, and his vital signs were as follows: heart rate, 111 beats/ min; systolic blood pressure, 135 mmHg; oxygen saturation, 95 per cent on ambient air; respiratory rate, 20 breaths/min; and body temperature, 37.8 °C. Physical examination revealed dental prosthesis with oral contamination; gingivitis; mild redness of the throat without pain; and no caries, swelling of the tonsils, hoarseness, cervical swelling, or tenderness. Blood tests revealed elevated inflammatory markers with a white cell count of 10 · 10/L and a C-reactive protein level of 12.8 mg/dL. Electrocardiography revealed elevated ST in multiple leads, and repeat CT revealed a deep neck, gas-forming abscess that extended into the right anterosuperior mediastinum, reaching the right diaphragm, accompanied by bilateral pleural and pericardial effusions with air in the pericardium (Fig. 1 A and B). Examination using a contrast-enhanced CT revealed a right jugular vein thromboembolism and right pulmonary artery branch embolism (Fig. 2 A and B). On the basis of these findings, the patient was a diagnosed as having DNM complicated by purulent pericarditis and LS, and emergency surgery was performed. Right cervicotomy and mediastinal drainage through a right-sided neck incision were initially performed, and because the pericardial space could not be adequately assessed by direct contrast inspection, pericardial drainage via the subxiphoid was subsequently performed. Pus was evacuated from both drains, and the pathogen identified on culture was Streptococcus constellatus (Streptococcus anginosus group). Subsequent blood cultures identified the same pathogen. Antibiotic therapy with sulbactam/ampicillin (3 g IV q6h) and clindamycin (600 mg IV q6h) from postoperative day (POD) 0 and anticoagulation with heparin (500–625 U/h IV) from POD 1, which was switched to rivaroxaban (30 mg) on POD 7, were initiated. The cervical and pericardial drainage tubes were removed on PODs 7 and 11, respectively. The disappearance of the right jugular vein thrombosis and pulmonary embolism were confirmed on CT, and the patient was discharged with no complications on POD 18. At the three-month follow-up, the patient was found to be healthy. DNM predominantly occurs because of oral or neck infections and is often fatal, if the inflammation widely spreads to the mediastinum and if the surgical drainage of the infection is not performed. Endo et al. classified Address correspondence and reprint requests to Takeshi Omura, M.D., Department of Surgery, Tokushima Prefectural Central Hospital, Kuramoto-cho, 1-10-3, Tokushima, Japan 770-8539. E-mail: omu@tph.gr.jp.