Chest Necrotizing Fasciitis with Mediastinitis

A 54-year-old woman with a history of psoriasis, which had been treated with methotrexate, and poorly-controlled diabetes (HbA1c 9.8 %) presented with anterior chest pain. She initially developed mild pain in the right upper-anterior chest. The patient was immediately referred to our hospital after the symptoms extended to the anterior chest wall and neck at 10 days after the onset of symptoms. Examinations showed crepitus and severe tenderness of the right to mid chest. While afebrile, a low blood pressure and tachycardia were also present. Chest CT (Picture 1-3) showed subcutaneous emphysema due to necrotizing fasciitis, which extended to the mediastinum. The diagnosis was confirmed by thoracotomy and debridement, which stabilized the condition enough to allow ambulatory rehabilitation by the 23rd of the hospital day. Despite the fact that the patient had no history of recent hospitalization, cultures of the necrotic tissue detected methicillin-resistant Staphylococcus aureus. Chest fasciitis causing mediastinitis is an extremely rare and significant comorbidity of diabetes (1, 2). The patient had poorly controlled diabetes and was undergoing immunosuppressant treatment, both of which are risk factors for this life-threatening disease.