A Case Report of Pulmonary Vein Stenosis Within the Labyrinth of Fibrosing Mediastinitis.

This case centers on a 76-year-old male experiencing exertional dyspnea and hemoptysis, with a medical history marked by recurrent pulmonary embolism and chronic obstructive pulmonary disease (COPD). Notably, he resides in a histoplasmosis-endemic area. A computed tomography (CT) pulmonary embolism scan revealed notable findings, including an enlarged right lower pulmonary artery, vascular congestion, atelectasis, and a mass exerting pressure on the right lower pulmonary vein. Biopsy results identified the mass as fibrosing mediastinitis, likely attributed to histoplasmosis. A transthoracic echocardiogram indicated right ventricular dilatation, impaired function, and a right ventricular systolic pressure of 63 mm Hg. During right heart catheterization, the patient displayed disparate pulmonary artery wedge pressures (PAWPs) between the right and left sides. This discrepancy was linked to a blunted back wave from the left atrium to the catheter, induced by pulmonary vein compression. Although an infrequent phenomenon, the recorded asymmetry in PAWPs played a crucial role in guiding accurate patient management. The absence of subsequent evaluation of PAWP on the left side could have altered the treatment plan, potentially delaying appropriate patient care. This case emphasizes the necessity of thorough exploration with right heart catheterization when clinical symptoms warrant, highlighting the importance of standardized practices in such procedures.

Relato de caso clínico de infecção odontogênica resultando em complicação cervicofacial / Reporte de caso clínico de infección odontogênica com resultado de complicación cervicofacial / Clinical case reportof odontogenic infectionresulting cervicofacial complication

Introdução: A saúde bucal é um aspecto que não deve ser subestimado pelos pacientes, principalmente se considerar que as infecções odontogênicas podem levar a quadros graves, incluindo complicações cervicotorácicas, como Mediastinite e cervicofaciais, como Angina de Ludwig. Para tanto, é imprescindível que os profissionais da odontologia saibam reconhecer os principais sinais e sintomas dessas infecções, sua evolução, conhecer as complicações associadas e qual o manejo adequado. Objetivo: Assim, é objetivo deste trabalho, relatar, discutir um caso clínico de uma infecção odontogênica grave que acarretou em complicação cervical, com trajeto em direção ao mediastino, necessitando manejo multidisciplinar, e explorar os principais aspectos desse quadro e a conduta necessária, que exige, no mínimo, intervenção cirúrgica, antibioticoterapia e manutenção das vias aéreas. Relato de caso: O caso trata de um paciente com infecção odontogênica, iniciada como uma pericoronarite do dente 38 semieruptado, que evoluiu para a área cervical, demandando imediata drenagem nesta região pois encaminhava-se para uma mediastinite. Após a drenagem cervical e antibioticoterapia e, assim que houve redução do trismo, foi removido o dente 38, evoluindo para a cura.Conclusões:As infecções odontogênicas, principalmente as que acometem os espaços fasciais e cervicais profundos, são potencialmente graves e devem ter suas principais manifestações clínicas entre os domínios de conhecimento dos profissionais Bucomaxilofaciais, pois necessitam de diagnóstico preciso, manejo rápido e tratamento adequado e precoce, considerando a velocidade com que podem evoluir (AU).

Introduction: Oral healthis an aspect that should not be underestimated by patients, especially considering that dental infections can lead to serious symptoms, including cervicothoracic complications, such as Mediastinitis and cervicofacial complications, such as Ludwig's Angina. Therefore, it is essential that dental professionals know how to recognize the main signs and symptoms of these infections, their evolution, know the associated complications and appropriate management.Objective: Thus, this work aims to report and discuss a clinical case of a serious odontogenic infection that resulted in a cervical complication, with a path towards the mediastinum, requiring multidisciplinary management, and to explore the main aspects of this condition and the necessary conduct, which requires, at least, surgical intervention, antibiotic therapy and airway maintenance.Case report: The case concerns a patient with odontogenic infection, which began as pericoronitis of semi-erupted tooth 38, which progressed to the cervical area, requiring immediate drainage in this region as it was heading towards mediastinitis. After cervical drainage and antibiotic therapy and, as soon as the trismus was reduced, tooth 38 was removed, progressing towards healing.Conclusions: Odontogenic infections, especially those that affect the fascial and deep cervical spaces, are potentially serious and should have their main clinical manifestations among the domains of knowledge ofOral and Maxillofacial professionals, as they require accurate diagnosis, rapid management and adequate and early treatment, considering the speed at which they can evolve (AU).

Introducción: La salud bucal es un aspecto que los pacientes no deben subestimar, especialmente considerando que las infecciones odontógenas pueden derivar en afecciones graves, incluidas complicaciones cervicotorácicas, como la mediastinitis, y complicaciones cervicofaciales, como la angina de Ludwig.Para ello, es fundamental que los profesionales odontológicos sepan reconocer las principales señalesy síntomas de estas infecciones, su evolución, conocer las complicaciones asociadas y el manejo adecuado.Objetivo: Así,el objetivo de este trabajo es reportar y discutir un caso clínico de infección odontogénica grave que resultó en una complicación cervical, con trayecto hacia el mediastino, que requirió manejo multidisciplinario, y explorar los principales aspectos de esta condicióny las medidas necesarias, que requiere, como mínimo, intervención quirúrgica, terapia con antibióticos y mantenimiento de las vías respiratorias.Reporte de caso: El caso se trata de un paciente con una infección odontogénica, que comenzó como pericoronaritis del diente 38 semi-erupcionado, la cual progresó hacia la zona cervical, requiriendo drenaje inmediato en esta región ya que se encaminaba para una mediastinitis.Después del drenaje cervical y la terapia antibiótica y, una vez reducido el trismo, se extrajo el diente 38, evolucijjonando hacia la cura.Conclusiones: Las infecciones odontogénicas, especialmente aquellas que afectan los espacios fasciales y cervicales profundos, son potencialmente graves y deben tener sus principales manifestaciones clínicas entre los dominios del conocimiento de los profesionales Orales y Maxilofaciales, pues requieren de un diagnóstico certero, un manejo rápido y un tratamiento adecuado y temprano, considerando la velocidad a la que pueden evolucionar (AU).

Ectopic pancreas tissue in the posterior mediastinum.

The occurrence of ectopic pancreas in the mediastinum is rare. Herein, we report a 22-year-old female who presented with right shoulder pain, dysphagia, fever and headaches. Chest computer tomography revealed a mass in the posterior mediastinum with accompanying signs of acute mediastinitis. Needle biopsy and fine-needle aspiration revealed ectopic gastral tissue and ectopic pancreas tissue, respectively. Surgical resection was attempted due to recurring acute pancreatitis episodes. However, due to chronic-inflammatory adhesions of the mass to the tracheal wall, en-bloc resection was not possible without major tracheal resection. Since then, recurring pancreatitis episodes have been treated conservatively with antibiotics. We report this case due to its differing clinical and radiological findings in comparison to previous case reports, none of which pertained a case of ectopic pancreas tissue in the posterior mediastinum with recurring acute pancreatitis and mediastinitis.

Descending necrotising mediastinitis: a rare entity in children.

We present a case of descending necrotising mediastinitis (DNM) originating from a retropharyngeal abscess in a healthy early childhood patient. The patient had a history of fever, odynophagia and refusal to eat, followed by rapid deterioration of the clinical state. Cervicothoracic CT was performed, which revealed a right parapharyngeal abscess, extending to the mediastinum and occupying the retropharyngeal/visceral space, with gaseous content throughout this collection, associated with bilateral pleural effusion, aspects compatible with DNM. She started broad-spectrum antibiotic therapy and transoral drainage of the parapharyngeal and retropharyngeal collections was performed under general anaesthesia. She was admitted to the intensive care unit. The patient showed clinical, analytical and imaging improvement, having been transferred to the ear, nose and throat department, with favourable evolution. Early diagnosis of DNM by cervicothoracic CT and multidisciplinary approaches, including intensive care, broad-spectrum antibiotics and surgical intervention, are crucial to minimise the morbidity and mortality.

Purulent pericarditis caused by methicillin-sensitive Staphylococcus aureus bacteriuria.

BACKGROUND: Purulent pericarditis (PP)- a purulent infection involving the pericardial space-requires a high index of suspicion for diagnosis as it often lacks characteristic signs of pericarditis and carries a mortality rate as high as 40% even with treatment. Common risk factors include immunosuppression, diabetes mellitus, thoracic surgery, malignancy, and uremia. Most reported cases of PP occur in individuals with predisposing risk factors, such as immunosuppression, and result from more commonly observed preceding infections, such as pneumonia, osteomyelitis, and meningitis. We report a case of PP due to asymptomatic bacteriuria in a previously immunocompetent individual on a short course of high-dose steroids. CASE PRESENTATION: An 81-year-old male presented for severe epigastric pain that worsened with inspiration. He had been on high-dose prednisone for presumed inflammatory hip pain. History was notable for urinary retention requiring intermittent self-catheterization and asymptomatic bacteriuria and urinary tract infections due to methicillin-sensitive Staphylococcus aureus (MSSA). During the index admission he was found to have a moderate pericardial effusion. Pericardial fluid cultures grew MSSA that had an identical antibiogram to that of the urine cultures. A diagnosis of purulent pericarditis was made. CONCLUSION: PP requires a high index of suspicion, especially in hosts with atypical risk factors. This is the second case of PP occurring as a result of asymptomatic MSSA bacteriuria. Through reporting this case we hope to highlight the importance of early recognition of PP and the clinical implications of asymptomatic MSSA bacteriuria in the setting of urinary instrumentation and steroid use.

[Descending Necrotizing Mediastinitis with Subclavian Vein Injury due to Cervical Re-debridement: Report of a Case].

A 58-year-old man was admitted to our hospital with fever and neck swelling after dental treatment. He was diagnosed with a cervical abscess and underwent cervical abscess drainage, but 1 week later he developed descending necrotizing mediastinitis and was referred to our department. He underwent mediastinal and pleural drainage, but neck abscess was recured, Re-debridment of the neck abscess resulted in bleeding from right subclavian vein. The bleeding was successfully stopped with TacoSeal after L-shaped sternotomyand dissection of sternocleidomostoid muscle.

Incidence and healing times of postoperative sternal wound infections: a retrospective observational single-centre study.

Objectives: Analyses of incidence and time required to heal sternal wound infections after heart surgery performed via a median sternotomy between 2020 and 2022. Results: Superficial wound infections (SWI) were five times more common (2.7%) than mediastinitis (0.5%) among 2693 patients. The median time between the operation and diagnosis of SWI was 26 (interquartile range [IQR] 15-33) days vs. 16 (IQR 9-25) days for mediastinitis (p = .12). Gram-negative bacteria caused 44% of the 85 infections. Sternal wound infection correlated to higher body mass index, female sex, smoking, diabetes mellitus, previous myocardial infarction, coronary artery bypass grafting, use of internal mammary graft, and re-entry for postoperative bleeding. Eight of 59 patients (13.6%) with sternal wound infections had bilateral mammary grafts, compared to 102 of 1191 patients (8.6%) without wound infections (p = .28). Negative pressure wound therapy was always used to treat mediastinitis and applied in 63% of patients with SWI. Two of 13 patients with mediastinitis (15%) and none of 72 patients with SWI died within 90 days after the operation. The median time until the wound healed was 1.9 (IQR 1.3-3.7) months after SWI vs. 1.7 (IQR 1.3-5.3) months after mediastinitis (p = .63). Six patients (7%) required longer than one year to treat the infection. Conclusions: Postoperative sternal wound infections usually appeared several weeks after surgery and were associated with factors as high body mass index, diabetes mellitus and coronary artery bypass. SWI were more common than mediastinitis and often required negative pressure wound therapy and similar treatment time as mediastinitis.

[Perioperative management of wounds associated with secondary sternal osteomyelitis and/or mediastinitis after sternotomy and its clinical effects].

Objective: To investigate the perioperative management of wounds associated with secondary sternal osteomyelitis and/or mediastinitis after sternotomy, and to evaluate its clinical effects. Methods: This study was a retrospective observational study. From January 2017 to December 2022, 36 patients with wounds associated with secondary sternal osteomyelitis and/or mediastinitis after sternotomy who were conformed to the inclusion criteria were admitted to the Burn Center of PLA of the First Affiliated Hospital of Air Force Medical University, including 23 males and 13 females, aged 25 to 81 years. Preparation for surgery was made. For patients with suspected retrosternal mediastinal abscess cavity, all cancellous bone of the unhealed sternum was bitten off to fully expose the retrosternal mediastinum, remove the source of infection and granulation tissue, and to fill the sternum defect with flipped unilateral pectoralis major muscle. For patients who had no retrosternal mediastinal infection but had fresh granulation tissue in unhealed sternal wounds, the necrotic tissue and a small amount of necrotic sternum were palliatively removed, and bilateral pectoralis major muscles were advanced and abutted to cover the sternal defect. After the skin in the donor area was closed by tension-relieving suture, continuous vacuum sealing drainage was performed, and continuous even infusion and lavage were added 24 hours later. The thorax was fixed with an armor-like chest strap, the patients were guided to breathe abdominally, with both upper limbs fixed to the lateral chest wall using a surgical restraint strap. The bacterial culture results of wound exudation specimens on admission were recorded. The wound condition observed during operation, debridement method, muscle flap covering method, intraoperative bleeding volume, days of postoperative infusion and lavage, lavage solution volume and changes on each day, and postoperative complications and wound healing time were recorded. After discharge, the wound healing quality, thorax shape, and mobility functions of thorax and both upper limbs were evaluated during follow-up. The stability and closure of sternum were observed by computed tomography (CT) reexamination. Results: On admission, among 36 patients, 33 cases were positive and 3 cases were negative in bacterial culture results of wound exudation specimens. Intraoperative observation showed that 26 patients had no retrosternal mediastinal infection but had fresh granulation tissue in unhealed sternal wounds, palliative debridement was performed and bilateral pectoralis major muscles were advanced and abutted to cover the defect. In 10 patients with suspected retrosternal mediastinal abscess cavity, the local sternum was completely removed by bite and the defect was covered using flipped unilateral pectoralis major muscle. During the operation, one patient experienced an innominate vein rupture and bleeding of approximately 3 000 mL during mediastinal exploration, and the remaining patients experienced bleeding of 100-1 000 mL. Postoperative infusion and lavage were performed for 4-7 days, with a lavage solution volume of 3 500-4 500 mL/d. The lavage solution gradually changed from dark red to light red and finally clear. Except for 1 patient who had suture rupture caused by lifting the patient under the armpit during nursing on the 3rd day after surgery, the wounds of the other patients healed smoothly after surgery, and the wound healing time of all patients was 7-21 days. Follow-up for 3 to 9 months after discharge showed that the patient who had suture rupture caused by armpit lifting died due to multiple organ failure. In 1 patient, the armor-like chest strap was removed 2 weeks after surgery, and the shoulder joint movement was not restricted, resulting in local rupture of the suture, which healed after dressing change. The wounds of the remaining patients healed well, and they resumed their daily life. The local skin of patient's pectoralis major muscle defect was slightly sunken and lower than that of the contralateral thorax in the patients undergoing treatment of pectoralis major muscle inversion, while no obvious thoracic deformity was observed in patients undergoing treatment with pectoralis major muscle propulsion and abutment. The chest and upper limb movement in all patients were slightly limited or normal. CT reexamination results of 10 patients showed that the sternum was stable, the local sternum was closed or covered completely with no lacuna or defects. Conclusions: Once the wound associated with secondary sternal osteomyelitis and/or mediastinitis after sternotomy is formed, individualized and precise debridement should be performed as soon as possible, different transfer ways of pectoralis major muscle flap should be chosen to cover the defect, and postoperative continuous infusion and lavage together with strict thorax and shoulder joint restraint and immobilization should be performed. This treatment strategy can ensure good wound healing without affecting the shape and function of the donor area.

Mediastinal Cryobiopsy for Pathological Diagnosis of Fibrosing Mediastinitis-Associated Pulmonary Hypertension.

INTRODUCTION: Fibrosing mediastinitis is a benign but fatal disorder characterized by the proliferation of fibrous tissue in the mediastinum, causing encasement of mediastinal organs and extrinsic compression of adjacent bronchovascular structures. FM-associated pulmonary hypertension (FM-PH) is a serious complication of FM, resulting from the external compression of lung vessels. Pathologic assessment is important for etiologic diagnosis and effective treatment of this disease. CASE PRESENTATION: A 59-year-old male patient presented at our hospital and was diagnosed with FM-PH. He declined surgical biopsy that is the reference standard for pathologic assessment, in consideration of the potential risks. Therefore, an endobronchial ultrasound examination was performed, which identified the subcarinal lesion. Under ultrasound guidance, four needle aspirations were carried out, followed by one cryobiopsy. Histopathological examination of transbronchial needle aspiration specimens was inconclusive, while samples from cryobiopsy suggested a diagnosis of idiopathic FM. Further immunophenotyping demonstrated the infiltration of lymphocytes, macrophages, and FOXP3-positive cells in FM-PH. CONCLUSION: Mediastinal cryobiopsy might be a novel and safe option for FM-PH patients who are unwilling or unsuitable for surgical procedure.

Postoperative mediastinitis and sternal osteitis after cardiac surgery caused by Mycoplasma hominis: A case report.

BACKGROUND: Mediastinitis and sternal osteitis are critical complications in cardiac surgery. Cases of these complications caused by Mycoplasma hominis are extremely rare. CASE PRESENTATION: We present a case of mediastinitis and sternal osteitis caused by M. hominis infection following ascending aortic replacement surgery. Whole gene sequencing analysis suggested the genitourinary tract as the most likely source of this M. hominis infection. Successful infection control was achieved through a regimen of moxifloxacin treatment. Additionally, a notable correlation was observed between serum levels of interleukin-6 and M. hominis infection. CONCLUSIONS: The significance of M. hominis as a potential cause of postoperative infection in cardiac surgery is still not fully recognized. Special attention should be paid to patients with bacteriologically negative infections, as M. hominis should not be disregarded, despite its rarity.

The usefulness of chest drain and epicardial pacing wire culture for diagnosing mediastinitis after open-heart surgery.

PURPOSE: Culture of extracted drains or epicardial pacing wires is an easy and noninvasive method for detecting mediastinitis after open-heart surgery, although studies on its sensitivity and specificity are limited. We, therefore, investigated the usefulness of this approach for diagnosing mediastinitis. METHODS: We retrospectively studied the culture results of drains and epicardial pacing wires extracted from 3308 patients. Prediction models of mediastinitis with and without culture results added to clinical risk factors identified by a logistic regression analysis were compared. RESULTS: The incidence of mediastinitis requiring surgery was 1.89% (n = 64). Staphylococcus was the causative bacterium in 64.0% of cases. The sensitivity, specificity, and positive and negative predictive values of positive culture results were 50.8%, 91.8%, 10.7%, and 99.0%, respectively. Methicillin-resistant Staphylococcus aureus had the highest positive predictive value (61.5%). A multivariate analysis identified preoperative hemodialysis (OR 5.40 [2.54-11.5], p < 0.01), long operative duration (p < 0.01), postoperative hemodialysis (OR 2.25 [1.01-4.98], p < 0.05), and positive culture result (OR 10.2 [5.88-17.7], p < 0.01) as independent risk factors. The addition of culture results to pre- and postoperative hemodialysis and a lengthy operative time improved the prediction of mediastinitis. CONCLUSIONS: A culture survey using extracted drains and epicardial pacing wires may provide useful information for diagnosing mediastinitis.

Surgery for fibrosing mediastinitis with severe pulmonary hypertension due to pulmonary venous stenosis.

A 21-year-old woman with severe pulmonary hypertension and circulatory collapse was referred to our hospital for possible lung transplantation with extracorporeal membrane oxygenation support. Computed tomography revealed severe stenosis of all 4 pulmonary veins, and fibrosing mediastinitis was suspected. Surgical reconstruction of the pulmonary veins was performed, and extracorporeal membrane oxygenation support was weaned off. After surgery, pulmonary vascular resistance normalized. This successful case demonstrates that surgical pulmonary venous reconstruction is an important treatment for fibrosing mediastinitis induced by pulmonary venous stenosis and pulmonary hypertension.

Mediastinitis secondary to invasive infection by group A Streptococcus in Spain.

This study describes 5 mediastinitis cases secondary to invasive group A Streptococcus (iGAS) disease in a recent outbreak in Spain. Among 398 iGAS cases between January 2019-March 2023, 5 (1.3%) were mediastinitis, 4 occurring in December 2022, all secondary to pneumonia or deep neck infection. We outline the clinical outcome with a review of the scarce pediatric literature.  Conclusion: mediastinistis is a rare but severe complication of iGAS and a high level of suspicion is required to diagnose it. What is Known: • Group A Streptococcus can cause invasive and severe infections in children. • Mediastinitis is a severe complication from some bacterial infections, mainly secondary due to deep-neck abscesses. What is New: • Mediastinitis is an unrecognized complication due to an invasive group A Streptococcus (iGAS) infection. • In cases of a deep-neck abscess or complicated pneumonia a high clinical suspicion of iGAS mediastinitis is required, especially when the clinical course is not favorable.

Poorly controlled diabetes mellitus is strongly associated with descending necrotizing mediastinitis of odontogenic origin.

OBJECTIVE: We hypothesized that poorly controlled diabetic status may be a negative prognostic factor for acute mediastinitis of odontogenic origin, and we conducted a cohort study to verify this hypothesis. STUDY DESIGN: Data were collected on all consecutive patients diagnosed with maxillofacial infections of odontogenic origin who received surgical treatment in the Oral and Maxillofacial Surgery Department. All patients included in the study were divided into 4 groups based on the presence or absence of diabetes and mediastinitis. Poorly controlled diabetic status constituted our primary predictor variable, and the occurrence of descending necrotizing mediastinitis was the outcome variable. RESULTS: All 7 patients with poorly controlled diabetes mellitus were complicated with descending necrotizing mediastinitis. An exact Fischer test was conducted to investigate the association of poorly controlled diabetes mellitus with descending necrotizing mediastinitis in patients admitted for surgical treatment of their maxillofacial collection. The result was significant at P < .01. CONCLUSION: This study represents the first scientific attempt to associate poorly controlled diabetes mellitus with descending necrotizing mediastinitis of odontogenic origin. Our results show evidently that these patients are more susceptible to deep space infections, which subsequently spread faster and are much more difficult to control.

Pericardial Closure With Expanded Polytetrafluoroethylene Patch in Left Ventricular Assist Device Surgery.

To reduce adhesions after left ventricular assist device (LVAD) implantation, pericardial closure using an expanded polytetrafluoroethylene (ePTFE) patch has been suggested. However, as foreign material, ePTFE patches could increase the risk of infectious complications. In this single-center retrospective study, we investigated outcomes of pericardial closure using an ePTFE patch in LVAD implantation. We included all patients who underwent LVAD implantation at our center between 2011 and 2020 (n = 166). Primary endpoint was development of mediastinitis at any point of time between LVAD implantation and heart transplantation (HTx) or death. Secondary endpoint was overall survival. Preoperative and postoperative clinical data were collected to ensure comparability between the groups. We included 166 patients with LVAD. A total of 116 patients (70%) underwent pericardial closure using an ePTFE patch. There were significant differences between the groups in treatment setting, previous cardiac surgery, Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level, development of driveline infection, and HTx. Patients with an ePTFE patch developed mediastinitis more frequently (16%) than patients without ePTFE patch (4%) ( p = 0.039). A significant difference in overall survival between the groups could not be confirmed ( p = 0.29). The use of PTFE patches for pericardial closure in LVAD implantation was associated with a higher incidence of mediastinitis, but not with a difference in overall survival.