Mediastinal actinomycosis masquerading as a mass: a case of progressive dysphagia in an immunocompromised patient.

Actinomycosis is a rare endogenous infection characterised by indolent progression, contiguous spreading, abscess formation and draining sinuses. Here, we present a case of Schaalia odontolytica causing a mediastinal abscess that is unique in its acuity and location. Our patient presented with worsening dysphagia, and CT of her chest revealed a new mass in the posterior mediastinum displacing the oesophagus. Oesophagram revealed mild motility disorder, but no masses or ulcers within the oesophagus. Oesophagogastroduodenoscopy with endoscopic ultrasound revealed extrinsic compression of the oesophagus. Fine-needle aspiration of the mass yielded purulent fluid, which was cultured. A single colony of S. odontolytica was isolated. Initially, medical treatment was favoured, but as she developed worsening dysphagia, the abscess was drained. She continued on long-term antibiotic therapy after drainage and had complete resolution of the abscess at 1 year.

Descending necrotizing mediastinitis caused by Streptococcus constellatus: A case report and review of the literature.

RATIONALE: Descending necrotizing mediastinitis (DNM) is a rare but severe mediastinal infection. If not diagnosed and treated promptly, the consequences can be very serious. Here, we shared a successful diagnosis and treatment case of DNM that originates from oral to neck and mediastinum caused by Streptococcus constellatus (S constellatus). S constellatus is a clinically uncommon gram-positive coccus and is known for its ability to form abscesses. Timely surgical drainage and the correct use of antibiotics are key to successful treatment. PATIENT CONCERNS: A 53-year-old male admitted to hospital with painful swelling of the right cheek, persistent oral pus and moderate fever lasting 1 week, followed by rapid development of a mediastinal abscess. DIAGNOSES: He was diagnosed with DNM caused by S constellatus. INTERVENTIONS: On the evening of admission, an emergency tracheotomy and thoracoscopic exploration and drainage of the right mediastinum, floor of the mouth, parapharynx and neck abscess were performed. Antibiotics were administered immediately. OUTCOMES: At 28 days post-operatively, the abscess was absorbed, bilateral lung exudate decreased and the patient temperature, aspartate transaminase, alanine transaminase, bilirubin and platelets returned to normal. The patient was discharged after completing 4 weeks of antibiotic therapy. Follow-up at 3 months after discharge revealed no recurrence of the abscess. LESSONS: Early surgical drainage and antibiotics treatment are important in mediastinal abscesses and infectious shock due to Streptococcus asteroids.

Chylomediastinum following mitral valve replacement.

Chylomediastinum is a rare but potentially serious complication. There is as yet no definitive treatment. We present an exceptional case of chylomediastinum due to mitral valve replacement. The patient was successfully treated using a conservative approach with total parenteral nutrition, nothing by mouth, and mediastinal tube drainage.

Cyanoacrylate injection treatment for postoperative leakage of Boerhaave's syndrome: A case report.

RATIONALE: Surgical treatment remains the most effective option for treating Boerhaave's syndrome. However, in cases of postoperative anastomotic leakage of Boerhaave's syndrome, endoscopic interventions such as over-the-scope clip, stenting, or cyanoacrylate injection have emerged over reoperation. PATIENT CONCERNS: We report the case of a 50-year-old male patient who presented with vomiting and abdominal pain after alcohol consumption. Laparoscopic surgery was performed for primary closure of a laceration at the lower esophagus, and for the closure of a Boerhaave's syndrome, which was detected by abdominal computed tomography. However, postoperative anastomotic leakage was confirmed through esophagography after the operation. In our case, endoscopic treatment with an over-the-scope clip and stenting were not effective for the repair of the anastomotic leakage, but cyanoacrylate injection successfully healed the anastomotic leakage. DIAGNOSES: Boerhaave's syndrome was initially detected by abdominal computed tomography, but postoperative anastomotic leakage after the operation was confirmed with esophagography. INTERVENTIONS: A total of 2.0 cc of N-butyl-2-cyanoacrylate and lipiodol mixture (at 1:1) was injected into the leakage tract through the perforation entrance. OUTCOMES: Complete healing of the anastomotic leakage was confirmed with a follow-up esophagoscopy. LESSONS: N-butyl-2-cyanocrylate injection treatment can be used as a rescue option for postoperative leakage when over-the-scope clips and stenting fail for this indication.

Boerhaave's syndrome after pentazocine-induced vomiting in a 21-year-old male with asthma: a case report.

Boerhaave's syndrome is an uncommon syndrome characterized by spontaneous rupture of the oesophagus with a high mortality rate. While excessive alcohol intake and binge-eating are the classic precipitants of this syndrome, medication-induced vomiting causing Booerhave's is quite uncommon. Traditionally managed operatively, conservative management is being increasingly reported in selected cases. We report the case of 21-year-old male with who developed sudden onset chest pain and dyspnoea after pentazocine induced vomiting. He was referred after lack of response to initial treatment for acute severe asthma. A chest CT scan showed pneumomediastinum, subcutaneous emphysema and oesophageal tear. He was managed conservatively with oxygen therapy, nil per mouth and antibiotics with improvement of symptoms and discharge after 8 days.

A Case Report of Subclinical Myasthenia Gravis Associated with Castleman's Disease.

BACKGROUND Castleman's disease is defined as a benign lymphoproliferative disorder of uncertain origin. It is most commonly found in the area of mediastinum. Castleman's disease is classified based on pathological features into hyaline-vascular, plasma cell, and mixed variants, which the hyaline-vascular variant is the commonest in association with Myasthenia Gravis. Castleman's Disease have been very rarely reported in Myasthenia Gravis, as it is associated with various clinical abnormalities. The enlarged localized lymph node is mainly diagnosed by incidental radiological findings due to the enlargement of thymus gland or by compression symptoms. CASE REPORT Here we report a case revolves around a 31-year-old Saudi woman who presented with a 2 years history of exertional dyspnea associated with mouth and eye ulcers. There were no other associated symptoms such as muscular weakness, rapid fatigue or drooping of the eyelids. She was referred to our institution for further investigations and management. She was diagnosed with a mediastinal thymoma that was detected based on a positive serology of antibody anti-acetylcholine receptor (AChR) testing and a computed tomography (CT) scan findings, she eventually underwent a bilateral thoracoscopic thymectomy. CONCLUSIONS The aim of this case report is to add more to the literature by reporting a rare case of an asymptomatic subclinical Myasthenia Gravis associated with Castleman's disease. It highlights the importance of considering a Castleman's Disease in an asymptomatic case who presented with a mediastinal mass and in order to avoid an unusual intraoperative finding such as massive bleeding by performing a biopsy and an angiography preoperatively.

A simple device designed to facilitate sternal closure and avoid complications.

We report an easy technique for sternal closure based on the use of a steel spoon. The spoon is placed under the line of the sternotomy where a stainless steel wire is passed through the bone. The tip of the wire passes through the bone and is then placed in the spoon which guides and facilitates the progressive passage of the wire through the bone. Finally, the spoon is symmetrically placed under the sternum on the opposite side.

Retrospective analysis of cellulitis of the floor of the mouth.

OBJECTIVES: To analyze clinical data of patients treated for mouth floor cellulitis during 2003-2006 years at the Department of Maxillofacial Surgery, Vilnius University Hospital Zalgiris Clinic and to compare the results with existing data. MATERIAL AND METHODS: Patient's gender, age, social insurance, demographic profile, preference of first visit, previous treatment, origin of inflammation, symptoms of disease, treatment protocol and outcomes were evaluated from 240 clinical records. RESULTS: The male-female ratio was 1.3:1. The mean age of patients was 43.18+/-7.56 years. 65% of patients were from urban. 47% of patients were employed, 15% retirees, 22% unemployed, 10% children, 2% students and 4% handicapped people. In 65% of cases primary diagnosis was incorrect. Majority of patients appealed to doctor on the first five days from the beginning of the disease. 93.7% of mouth floor cellulites were odontogenic origin. In 32.9% of the patients at the time of first examination the extension of inflammation into parapharyngeal, pterygomandibular spaces or neck together with mouth floor cellulitis was diagnosed. In 1.7% (in 4 out of 240) of cases infection extended into the neck and parapharyngeal spaces despite treatment. In 2% (in 5 out of 240) of cases infection extended to mediastinum. CONCLUSIONS: Despite the aggressive treatment serious complications still are possible. Delayed treatment procedures might determine poor prognosis.

[Human adjuvant disease which developed after silicone augumentation mammoplasty].

A 73-year-old woman was admitted to our hospital to evaluate mediastinal lymphadenopathy found on a chest CT scan. She had undergone mammoplasty with silicone augmentation 50 years previously and had the implants removed 5 years previously. Biopsied specimens of a mediastinal lymph node under video-assisted thoracic surgery (VATS) revealed multiple hyalinized non-caseating epithelioid cell granulomas and multinucleated giant cells and foamy macrophages containing some vacuoles. According to these clinicopathological findings, we diagnosed human adjuvant disease which developed after mammoplasty with silicone augmentation. In cases of mammoplasty, we should pay attention to the complication of chronic thoracic disorder as a human adjuvant disease.

[Mediastinal abdominal wall fistula due to ePTFE membrane].

A 78-year-old woman who had undergone double valve replacement 13 years before was referred to our department because of postoperative wound dehiscence and exudate. Although the result of exudate culture was negative, the wound was disinfected continuously for 4 weeks and showed a transient remission. However, the exudate was observed again 3 weeks later. By chest computed tomography (CT), a highly bright shadow was revealed in the mediastinum, which was suspected to be a foreign body and, therefore, the cause of the exudate. Considering the possibility of infection, the patient underwent an operation. Following incision of the epigastric region and the resection of the xiphoid process, ePTFE membrane with poor granulation tissue was found. The membrane was removed, the lesion was washed with warm saline, and then the wound was closed. The postoperative course was uneventful without recurrence. This complication was considered to be caused by biological reaction to a foreign body.

[Treatment Experience of Continuous Negative Pressure Drainage in the Acute Anterior Mediastinal Infection of Oropharyngeal Origined].

BACKGROUND: Mediastinal infection is a serious infection of mediastinal connective tissue, with more complications and higher mortality. Application of broad-spectrum antibiotics and nutritional support, early sufficient drainage is the key to successful treatment. In the mode of drainage, this paper discusses the application of continuous negative pressure drainage technique to treat acute anterior mediastinal infection of severe mouth pharynx source, and the good results are summarized and shared. METHODS: In January to December in 2017, a total of 17 cases treated acute mediastinal infection is derived from the throat, has formed a mediastinal abscess, surgery adopts retrosternal counterpart negative pressure drainage way, namely the sternum nest and free sternum xiphoid process under the incision on the first mediastinal clearance, make breakthrough and placed drainage device, suture closed wound, continuous negative pressure drainage, negative pressure using 3 cm-5 cm water column. RESULTS: Among the 17 patients, 14 patients were relieved by continuous negative pressure drainage, and then the drainage tube was removed. In 2 cases, the infection broke into the right thoracic cavity, and the closed drainage caused the negative pressure to disappear, and the negative pressure drainage was replaced by the conventional drainage, and the drainage tube was removed after the drainage tube was clear. One patient had formed a mediastinal abscess incision drainage time later, complicated with septic shock and sepsis, resulting in the death of multiple organ failure. CONCLUSIONS: The traditional treatment of severe acute mediastinal infection is sternal incision and drainage. Continuous negative pressure drainage adequate drainage of mediastinal can relieve patients' pain, effusion, and avoid the dressing out repeatedly. It is an effective method. However, there are limitations in this method, which need to be further optimized.

An Absorbable Hydrogel Spray Reduces Postoperative Mediastinal Adhesions After Congenital Heart Surgery.

BACKGROUND: Adhesions encountered during reoperative cardiac surgery can prolong operative time and increase operative risk. The purpose of this clinical study was to investigate the antiadhesion property of a synthetic bioabsorbable polymer spray after cardiac reoperations in infants. METHODS: A prospective randomized double-blinded study was designed. Forty infants requiring staged cardiac operations were randomly allocated to a study group (n = 20) or a control group (n = 20). The appropriate volume of the polymer was sprayed onto the mediastinal surfaces before chest closure after the first surgical procedure in the study group. At reoperation, adhesions were evaluated by a blinded investigator following a 5-grade scoring system. Five predetermined anatomic areas were scored. Incision to extracorporeal circulation time was also analyzed. RESULTS: In all, 40 subjects were enrolled into the study. Four babies died before the second operation. Three others were missed for reevaluation. The control group (n = 16) had longer incision to extracorporeal circulation time (38 ± 10 minutes) than the study group (n = 17; 23 ± 6 minutes; p < 0.001). The control subjects had significantly more severe adhesions than the study group at all five mediastinal areas: (1) retrosternal (p < 0.001); (2) base of the heart (large vessels [p < 0.05]); (3) right side (p < 0.01); (4) left side (p < 0.02); and (5) diaphragmatic side of the mediastinum (p < 0.001). CONCLUSIONS: The use of synthetic bioabsorbable polymer sealant spray at the end of primary pediatric cardiac surgery reduces the intensity of mediastinal adhesions and the reentry time in infants undergoing repeat median sternotomy.

On-pump vs. off-pump coronary artery bypass surgery at a non-academic community hospital: have biocompatibility improvements eliminated the superiority of off-pump surgery?

OBJECTIVES: Standard coronary artery bypass grafting (CABG) surgery involves cardiopulmonary bypass (CPB) but given concerns over neurological and inflammatory complications related to CPB, many patients receive so-called off-pump procedures (OPCABG). Our objective is to determine if the recent improvements in the biocompatibility of CPB circuitry have improved post-operative outcomes at the community hospital level, particularly in terms of hospital length of stay (LOS), stroke and post-operative infection. METHODS: We analyzed hospital LOS, incidence of stroke, infection, and mortality along with several clinical variables in 209 patients (38% underwent OPCABG) at a single, non academic community hospital. We constructed a series of forward, stepwise, multiple-variable regression models using mediastinal infection, hospital LOS, and stroke as dependant variables. RESULTS: OPCABG was associated with a shorter median hospital LOS (3 days vs. 4 days; p=0.0001) and a reduced occurrence of stroke (0% vs. 7.6%; p=0.03). However, mediastinal infections occurred more commonly in OPCABG cases (10% vs. 2.2%; p=0.02). CABG and pre-existing renal disease were predictors of increased hospital LOS (p< 0.0001) whereas CABG was the only factor associated with decreased risk of mediastinal infection (OR=0.21 (0.05-0.80); p=0.02). CONCLUSIONS: At the community level, OPCABG appears to be superior in terms of LOS and incidence of stroke. Paradoxically, CABG surgery demonstrates a reduced rate of mediastinal infection.

Mediastinal Abscess Caused by an Expanded Polytetrafluoroethylene Membrane.

A 76-year-old man who had undergone tricuspid annuloplasty 13 years earlier was admitted to our hospital because of a high fever. Although he was treated with antibiotics for pneumonia, a mild fever persisted. Computed tomography and gallium scintigraphy revealed a mediastinal abscess with an expanded polytetrafluoroethylene (ePTFE) membrane. There were no positive cultures or sternal changes indicating poststernotomy mediastinitis. The membrane was removed by a left parasternal approach without resternotomy, and its total removal was essential for the patient's recovery. This is the first reported case of sterile mediastinal abscess caused by an ePTFE membrane after a cardiac operation.

Endoscopic Treatment of Boerhaave Syndrome Using Polyglycolic Acid Sheets and Fibrin Glue: A Report of Two Cases.

Boerhaave syndrome, the spontaneous perforation of the esophagus, is an emergency, life-threatening condition. Current endoscopic treatment options include clipping and stenting, but the use of polyglycolic acid (PGA) sheets for treating the condition has not been reported. In recent years, PGA sheets have been used after endoscopic submucosal dissection to prevent perforations and stricture formation in patients treated for early-stage carcinoma. We report the cases of two patients with Boerhaave syndrome who were successfully treated using PGA sheets. The present clinical outcomes suggest that the use of PGA sheets is feasible and safe for treating patients with Boerhaave syndrome, and that they may be another treatment option.

Closure of a Traumatic Esophagomediastinal Fistula in a Child by Endoscopic Fulguration and Fibrin Injection.

Posttraumatic esophagomediastinal fistula is an uncommon clinical entity that warrants surgical awareness due to its life-threatening potential. Its management, especially in previously operated field, is controversial and several endoscopic methods are being proposed as alternatives. Ours is the first report of endoscopic fulguration and fibrin injection in successful closure of such fistula. A 9-year-old female sustained complete tracheoesophageal transection from a gunshot wound to the neck and underwent immediate primary repair. She presented nine months later with fevers and swelling over anterior neck. CT revealed air tracking posteriorly to the dorsal neck and inferiorly to the mediastinum. Considering difficulty of open surgical approach, endoscopic intervention was attempted. Posterior wall fistula was identified via microlaryngoscopy above the esophageal anastomosis. The fistula tract was de-epithelialized via a Bugbee fulgurating electrode and then sealed with fibrin glue. Consequent imaging studies demonstrated complete occlusion of the fistula. Posterior posttraumatic esophagomediastinal fistula presents a challenging scenario from a surgical standpoint, as it combines difficulty of safe approach, high rate of injury to surrounding structures, and significant postoperative recurrence rate. Endoscopic Bugbee fulguration and fibrin glue injection are a safe and effective alternative to the traditional approach.

[Endoscopic vacuum therapy for Boerhaave's syndrome]. / Endoskopische Vakuumtherapie beim Boerhaave-Syndrom.

INTRODUCTION: Operative and interventional treatment of Boerhaave's syndrome include closure of the esophageal defect and drainage of the septic focus. Initial reports on the use of endoscopic vacuum therapy (EVT) of Boerhaave's syndrome are now available. This article describes the experiences gained from the clinical application in two patients using this new surgical endoscopic procedure. The current literature regarding treatment of Boerhaave's syndrome is presented. MATERIAL AND METHODS: Open-pore drainage is endoscopically placed either through the transmural defect in the extraluminal wound cavity (intracavitary EVT) or overlapping the defect into the esophageal lumen (intraluminal EVT). The application of a negative pressure results in active drainage directed to the lumen and simultaneously in defect closure. Through these therapeutic measures the perforation defect and the septic focus can be healed. Open-pore drains are manufactured from drainage tubes and open-pore foam or an open-pore film. RESULTS: In both patients the distal esophageal perforation defects were completely healed using EVT. In 1 patient the treatment with EVT alone lasted 8 days. For the second patient EVT was combined with an open thoracotomy for decortication of pleural empyema. The treatment with EVT lasted 23 days and 1 cycle of EVT was carried out with an new open-pore film drainage (OFD). Surgical treatment to close the defect or an esophageal resection was not necessary for both patients. In the currently available studies and single case reports of ETV for Boerhaave's syndrome, 11 patients (84 %) of a total of 13 patients have been successfully treated. CONCLUSION: First clinical experiences have demonstrated that with EVT draining of the septic focus and closure of the Boerhaave defect at the gastroesophageal junction can be achieved. The EVT is an organ-preserving endoscopic surgical treatment, which can be an alternative and complementary to traditional surgery.