Extensive fibrotic wrapping of the heart: a rare echocardiographic diagnosis.

BACKGROUND: Fibrosing mediastinitis (FM) is considered a benign disease, but it can be fatal if progression leads to compression of the hilum of the lungs or invasion of the heart. Echocardiographic reports of this disease are very rare. CASE PRESENTATION: We present a 14-year-old male patient whose non-enhanced chest computed tomography showed unclear soft-tissue dense lesions in the anterior superior mediastinum. Echocardiography showed the heart was extensively wrapped by soft tissue lesions. The histology confirmed FM. CONCLUSIONS: When FM affects the heart, echocardiography can help to characterize the disease and aid in the diagnosis. Echocardiography should be considered an important tool to follow the progression of this disease and guide the therapeutic approach.

Unusual lymphadenopathy diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration.

Oxidized cellulose, used as hemostatic in thoracic surgery, may cause in some cases foreign body reactions, and simulate other diseases. We report the case of a 39-year-old man operated on a middle lobe lobectomy for atypical carcinoid. The follow up chest-CT showed enlarged mediastinal lymph nodes, so endobronchial ultrasound-guided transbronchial needle aspiration was performed suspecting recurrence of the tumor. The cytology results showed amorphous fragments such as foreign body reaction secondary to Pahacel®, used as hemostatic during the surgery. A few days later, the patient was re-operated on suspicion of mediastinitis induced by the endoscopic procedure. The aim of this case is to consider the foreign body reaction to Pahacel®, in patients with postoperative thoracic lymphadenopathy. It is also important to remember that in these patients the endoscopic procedures allow the diagnosis but may cause mediastinitis.

Surgical treatment for mediastinal abscess induced by endobronchial ultrasound-guided transbronchial needle aspiration: a case report and literature review.

BACKGROUND: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a useful and less invasive procedure for the definitive diagnosis of mediastinal and hilar lymph nodes. However, infectious complications can occur after EBUS-TBNA, although they are extremely rare. CASE PRESENTATION: A 66-year-old man with necrotic and swollen lower paratracheal lymph nodes underwent EBUS-TBNA. A mediastinal abscess developed 9 days post-procedure. Surgical drainage and debridement of the abscess were performed along with lymph node biopsy followed by daily washing of the thoracic cavity. Surgical treatment was effective, leading to remission of the abscess. Biopsy revealed that the tumor was squamous cell carcinoma with no radiologically detected cancer elsewhere in the body. Mediastinal lung cancer was thus confirmed. Subsequent chemoradiotherapy led to the remission of the tumor. CONCLUSIONS: Mediastinitis after EBUS-TBNA is rare but should be considered, particularly if the target lymph nodes are necrotic. Mediastinitis can lead to serious and rapid deterioration of the patient's condition, for which surgical intervention is the treatment of choice.

Postradiation-associated sclerosing mediastinitis diagnosed in fine needle aspiration specimen: A cytological-pathological correlation.

Sclerosing mediastinitis (SM) is an aggressive fibroproliferative process in the mediastinum that may lead to encasement of mediastinal structures within a dense fibrotic mass. This disease may cause significant clinical complications, morbidity, and even mortality. The etiology and pathogenesis of SM is unclear and in more than one third of cases remains idiopathic. Among the known causes of SM, granulomatous infection is the commonest. Association of SM with radiation therapy has been rarely reported. Herein, we are reporting a case of postradiation sclerosing mediastinitis diagnosed in fine needle aspiration (FNA) specimen. To our knowledge, this is the first reported case of postradiation sclerosing mediastinitis with unusual striking intracytoplasmic glycogen accumulation. Having high index of suspicion and awareness of the fact that this entity may be also associated with radiation therapy, will be helpful in avoiding diagnostic pitfalls in FNA specimens and guiding proper clinical management.

[Necrotizing fasciitis in head and neck area]. / Nekrotizáló fasciitis a fej-nyaki régióban.

Necrotizing fasciitis is a fulminant infection of the deeper layers of skin and subcutaneous tissues characterized by progressive soft tissue necrosis and high mortality. It rarely occurs in the head and neck area. The clinical picture includes non-specific but typical local and systemic symptoms. The treatment is a complex, multidisciplinary task which includes radical surgical exploration, debridement and drainage, empirically started and then targeted intravenous antibiotics and supportive therapy. Authors report a case of necrotizing fasciitis localized on the right side of the face which caused multi-organ failure and phlegmone of the neck.

[CAUSES AND WAYS OF THE NECK PHLEGMON SPREADING ON MEDIASTINUM WITH A DESCENDING PURULENT MEDIASTINITIS OCCURRENCE].

Results of treatment in 2000-2016 yrs of 183 patients for the neck phlegmon were analyzed. In 60 (32.8%) of them a descending purulent mediastinitis (DPM) was diagnosed. The main causes of the DPM occurrence were tonsilogenic and odontogenous factors. Postoperative lethality in DPM have constituted 25%.

Clinical features and outcome of patients with descending necrotizing mediastinitis: prospective analysis of 34 cases.

PURPOSE: We aimed to investigate clinical features of patients with descending necrotizing mediastinitis (DNM) in order to improve management and outcome. METHODS: We prospectively examined all patients with DNM admitted to the Intensive Care Unit (ICU) during the period from April 2007 to December 2013. Demographics, clinical features, microbiology, medical and surgical treatment data were recorded. Survivor and nonsurvivor groups were analyzed to identify factors associated with mortality. RESULTS: Overall, 34 patients with DNM have been included. The mean age was 46.8 ± 11.2 years (range 24-70). The male/female ratio was 3.25. DNM arose from odontogenic infection in 22 (65%) patients; from peritonsillar abscess in 9 (26%) patients and from paranasal sinus in 3 (9%) patients. Microbiological cultures revealed a high percentage of aerobic/anaerobic coinfection. Nonsurvivors were statistically more likely to have higher SAPS II score (mean difference 19.1, 95% CI 12.3-25.9 P < 0.01) and more severe disease (P < 0.01) than survivors. Positive correlation was found between time to ICU admission after head or neck infection diagnosis and SAPS II score (ρ = 0.5, P = 0.03). The same was true for ICU length of stay and time to ICU admission (ρ = 0.6, P < 0.01) and time to surgery (ρ = 0.5, P = 0.03). Surgical treatments consisted in: transcervical drainage in 14 cases, (42%); irrigation through subxiphoid and cervical incisions of the anterior mediastinum with additional percutaneous thoracic drainage when necessary in ten cases, (29 %); thoracotomy with radical mediastinal surgical debridement, excision of necrotic tissue and decortication in ten cases, (29%). We have found a mortality rate of 12%. Patients with DNM type IIB were admitted to the ICU later than patients with DNM type I and type IIA (mean difference 3.2 days, 95% CI 1.2-5.1, P 0.02). CONCLUSIONS: Prompt ICU admission in order to manage severe sepsis and/or septic shock, along with early and aggressive surgery and adequate antimicrobial therapy, could be key factors in reducing DNM mortality.

[Non-neoplastic lesions of the mediastinum]. / Nichtneoplastische Läsionen des Mediastinums.

The mediastinum is a complex body region of limited space but containing numerous organs of different embryonic origins. A variety of lesions that are difficult to distinguish from each other can occur here. Non-neoplastic lesions of the mediastinum represent important differential diagnostic pitfalls to mediastinal tumors, clinically, radiologically and histopathologically. It is important to bear these lesions in mind and to adequately verify or exclude them before starting further differential diagnostic considerations on mediastinal neoplasms. The most common non-neoplastic lesions in this region include cysts and lymphadenopathies. Mediastinal cysts result from abnormal events in the branching of the tracheobronchial tree, the pharyngeal pouches, the primary intestines, the pleuropericardial membranes and the brain meninges or are complications of inflammatory and hydrostatic processes. The histogenesis of the lining epithelium and the cyst wall structure are decisive for the exact classification. The histopathologically most prevalent patterns of mediastinal lymphadenopathies are those accompanied by increased histiocytes and Castleman's disease. Sclerosis is a non-specific reaction pattern of the mediastinum and can be associated with many processes; therefore, when establishing the diagnosis of sclerosing mediastinitis, several differential diagnoses have to be excluded. Simple thymic hyperplasia can be accompanied by considerable increase in organ size with severe local symptoms, while follicular thymic hyperplasia is often associated with myasthenia gravis and represents the most common findings in non-thymoma thymectomy specimens.

[[Treatment and prophylaxis of complications of the sternotomy access in thoracic operations].]

Literature data and own experience of the treatment complications, occurring after tho- racic operations, using sternotomy access, were presented. Special attention was drawn to postoperative sternomediastinitis - most frequent infectious complication. Measures for the sternomediastinitis prophylaxis, methods of its diagnosis and treat- ment were presented.

Descending mediastinitis in Epstein-Barr virus infection.

Our case report describes a previously healthy 34-year-old male who develops a descending mediastinitis as a complication of an Epstein-Barr virus (EBV) infection. The mediastinitis was suspected to have developed by a breakthrough of a peritonsillar abscess through the space between the alar and prevertebral space.

Diagnostic value of 99mTc-HMPAO-labeled leukocytes scintigraphy in suspicion of post-sternotomy mediastinitis relapse.

BACKGROUND: The diagnostic value of radiolabeled white blood cells (WBCs) scintigraphy in mediastinitis is well established, but data in the specific context of relapse are lacking. The present study aimed at evaluation of the diagnostic value of WBCs scintigraphy in suspicion of mediastinitis relapse after prior surgical revision. METHODS AND RESULTS: Multiple planar incidences of the chest were acquired 4 and 20 hours after injection of labeled WBC in 43 patients. In case of non-conclusive scintigraphy, a second scan was performed 2-3 weeks after the first one. The diagnosis of infection was based on positive bacteriological results; otherwise patients were followed up for at least 1 year. Out of 39 analyzable patients, 17 (44%) were diagnosed with mediastinitis relapse. After the first scan, 32 of 39 were correctly classified, 2 were false positive, and 5 were not conclusive. After completion of an additional scan in the latter 5 patients, 36 of 39 were correctly classified and 3 were false positive (100% sensitivity, 86% specificity, 85% positive predictive value, and 100% negative predictive value). CONCLUSIONS: In the specific context of suspicion of mediastinitis relapse, the optimal diagnostic value was achieved by repeating the scan when the first one was not conclusive. In this context, a negative WBC scintigraphy was able to rule out infection, with potential major impact on therapeutic management in patients with poor clinical status.

[Descending necrotizing mediastinitis resulting from acute epiglottitis; report of a case].

Descending necrotizing mediastinitis (DNM) is a serious condition due to abscess spreading from neck into mediastinum. We report a case of DNM following acute epiglottitis and abscess. A 59-year old male visited our hospital for parotid swelling, pyrexia, and dyspnea, and was diagnosed as having acute epiglottitis at otology and hospitalized. Despite right tonsillectomy, drainage and tracheostomy on day 6 after hospitalization, he developed DNM and was referred to our department. Drainage of mediastinal regions( anterior to the trachea and tracheal bifurcation, inferoposterior mediastinum and posterior to the left main bronchus) was performed on day 14 after hospitalization. Postoperative course was uneventful.

Fibrotic phenotype of IgG4-related disease.

A prompt response to glucocorticoids is a clinical hallmark of IgG4-related disease. However, manifestations characterised by prominent tissue fibrosis on histological examination can be less responsive to glucocorticoid therapy than other types of IgG4-related disease. These manifestations include retroperitoneal fibrosis, fibrosing mediastinitis, Riedel thyroiditis, orbital pseudotumor, and hypertrophic pachymeningitis, among others. To explain this discrepancy, a preliminary distinction into proliferative and fibrotic phenotypes of IgG4-related disease has been proposed on the basis of clinical presentation, pathological features, and response to immunosuppressive therapy. Implications of this classification for patient management remain an important area of investigation. In this Series paper, we aim to dissect the pathophysiology of tissue fibrosis in IgG4-related disease and discuss how clinicians should approach the management of fibrotic manifestations of IgG4-related disease based on the most recent diagnostic and therapeutic developments.

[Fibrosing mediastinitis diagnosed by thoracoscopic biopsy].

We report a rare case of fibrosing mediastinitis diagnosed by thoracoscopic biopsy. A 56-year-old female visited our hospital with an abnormal mediastinal shadow on chest X ray. Chest computed tomography revealed a paravertebral tumor from Th9 to Th11. Pathological examination of thoracoscopic biopsy specimen showed fibrous tissue with mild inflammation and no malignant feature. Final diagnosis was idiopathic fibrosing mediastinitis. The paravertebral lesion shrinked spontaneously 5 months later after biopsy.

[Diffuse descending necrotizing mediastinitis with cardiac tamponade;report of a case].

Descending necrotizing mediastinitis( DNM) is often a lethal condition resulting from odontogenic or cervical infection, with a previously reported mortality rate of 25 to 40%, which is known to accompany occasional pericardial effusion. Here, we report a case of diffuse DNM with cardiac tamponade.

[Necrotizing fasciitis of the neck]. / Nekroticni fascitis vrata.

Necrotizing fasciitis is a rare and rapidly progressive infection characterized by necrosis of the superficial fascia and spread on the surrounding skin or muscles, which can be fatal. It usually occurs in the limbs, abdominal wall and perineum. In this retrospective review, the authors present 15 patients with cervical necrotizing fasciitis. The patient mean age was 54.7 years and they had one or more comorbid health problems. Five of them had descending necrotizing mediastinitis and three had progressive sepsis with toxic shock syndrome. Broad-spectrum intravenous antibiotic therapy was administered to all patients immediately, and in three of them we used five-day intravenous immunoglobulin therapy for the signs of toxic shock syndrome. After positive computed tomography imaging for necrotizing fasciitis, we used surgical exploration and debridement of necrotic tissue. In five patients, the initial surgery also included mediastinal transcervical drainage. Preoperative tracheotomy was performed in six patients and delayed tracheotomy in one patient. Histopathologically, all cases showed extensive necrosis of debrided fascia and vascular thrombosis of the neck soft tissue. The mortality rate was 6.7% (1/15). The authors point to the importance of early diagnosis and timely surgical management, broad-spectrum antibiotics and intravenous immunoglobulin therapy when patients are too unstable to undergo surgery.

[Surgical management of descending necrotizing mediastinitis]. / Tratamiento quirúrgico de la mediastinitis necrosante descendente.

INTRODUCTION: Descending necrotizing mediastinitis (DNM) is a serious infection which occurs as a complication of oropharyngeal infection. Its surgical management and the routine transthoracic approach remain controversial. In this article we report our experience in the management of this disease, and review the different surgical approaches that have been reported in the medical literature. MATERIAL AND METHODS: A retrospective review was made of the clinical records of 29 patients treated between 1988 and 2009. Several demographic variables were analyzed, origin of the initial infection, stage of the disease according to Endo's classification, surgical technique and outcome. RESULTS: Surgical treatment consisted of both cervical and mediastinal drainage and radical debridement. The mediastinal drainage was made through a transcervical approach in 10 cases and transthoracic in 19, depending on the extent of the mediastinitis. The outcome was satisfactory in 24 patients and 5 died (mortality 17.2%). CONCLUSIONS: According to our results and the conclusions of the main authors, we recommend a prompt and aggressive surgery with a transthoracic approach in cases of widespread DNM.

Percutaneous vascular stent implantation as treatment for central vascular obstruction due to fibrosing mediastinitis.

BACKGROUND: Fibrosing Mediastinitis (FM) is a rare complication of infection with Histoplasma capsulatum that can lead to obstruction of pulmonary and systemic vasculature and large airways, often resulting in significant morbidity and mortality. Medical therapy is ineffective, and surgical intervention is often not feasible. Stent implantation offers a potential treatment for vascular obstruction due to FM, but this has not been well studied. METHODS AND RESULTS: We conducted a retrospective review of all patients undergoing cardiac catheterization for FM. Anatomic site of stenosis and hemodynamic information before and after intervention, as well as clinical presentation and follow-up data, were recorded. From 1996 to 2008, 58 patients underwent cardiac catheterization for FM, with intervention performed in 40 (69%). A total of 77 stents were used to relieve 59 lesions (pulmonary artery=26, pulmonary vein=21, and superior vena cava=12). Significant reduction in pressure gradients (P<0.001) and increase in vessel caliber (P<0.001) were seen at all locations. Symptomatic recurrent stenosis requiring further intervention occurred in 11 patients (28%). Median time to recurrence was 115 months. Thirty-two (87%) of 37 patients for whom follow-up was available reported symptomatic improvement after stent placement. PROCEDURE: related complications occurred in 14 patients (24%). Overall mortality was 19%, with the majority of deaths in patients with bilateral disease. Among patients with bilateral disease, intervention was associated with improved survival at 5 years. CONCLUSION: Percutaneous vascular stent implantation is an effective therapy for central vascular obstruction due to FM, providing significant relief of anatomic obstruction and sustained clinical improvement.

Endovascular management of carotid artery stenosis secondary to sclerosing mediastinitis.

Sclerosing mediastinitis is a rare, progressive condition characterized by extensive fibrotic reaction. We report the first known case of symptomatic, extrinsic compression of the carotid artery by fibrotic extension of sclerosing mediastinitis. A 54-year-old woman began experiencing neurologic symptoms from extension of a known mediastinal mass resulting in 70% to 79% stenosis of the right internal carotid artery. The stenosis was treated with endovascular stenting. Completion angiogram revealed a good result with <10% residual stenosis. At 18-month follow-up, the patient was symptom free without evidence of re-stenosis. Endovascular therapy provides a novel and durable solution in the midterm to this very rare problem.

Cervical necrotizing fasciitis with descending mediastinitis: literature review and case report.

Cervical necrotizing fasciitis (CNF) can develop from odontogenic infections that spread to the deep fascial planes of the neck. This polymicrobial infection is rapidly progressive, destructive, and often fatal. Prompt diagnosis, recognition of acuity, aggressive, repeated surgical treatment, and medical management contribute to improved survival. Nevertheless, the progression of the disease to descending mediastinitis and septic shock leads to a poor prognosis and decreased survival. A comprehensive review of the current data regarding CNF was conducted using MEDLINE, PubMed, Scopus, and Google Scholar. The diagnostic elements, comorbid conditions, treatment modalities, complications, and survival rates were analyzed. CNF has a reported mortality rate of 7% to 20%, depending on the extent of neck involvement. When the disease progresses into the thorax, such as in the subset of patients with CNF complicated by descending necrotizing mediastinitis (DNM) of odontogenic origin, the mortality rate increases to 41%. This is greater than the reported mortality rate of 22% for DNM in cardiothoracic studies. When DNM is present, the risk of developing septic shock appears to be much greater, 22% versus 7%. In the presence of CNF, DNM, and sepsis, the mortality rate increases to 64%. Those who survive CNF complicated by DNM and sepsis have truly beaten the odds. CNF is an uncommon, but potentially fatal, condition that oral and maxillofacial surgeons might be called on to manage emergently. Treatment includes surgery and medical intensive care. Surgeons offer the best odds of patient survival by following these basic principles: airway security, early aggressive incision and drainage plus debridement with thoracotomy, as needed, close surveillance with computed tomography, and a low threshold for retreatment. In immunocompromised patients, even greater vigilance is required. Antibiotic therapy should be adjusted as cultures and sensitivities become available. Advances in interventional radiology might lead to improved survival by allowing guided minimally invasive drainage in critically ill patients who cannot tolerate additional surgical insult. Despite the technologic advances in diagnosis and treatment, CNF complicated by DNM mediastinitis and sepsis still results in astoundingly high mortality.