Mediastinitis

Last updated
Mediastinitis
Mediastinum.jpg
Mediastinum
Specialty Pulmonology   OOjs UI icon edit-ltr-progressive.svg

Mediastinitis is inflammation of the tissues in the mid-chest, or mediastinum. It can be either acute or chronic. It is thought to be due to four different etiologies: [1]

Contents

Acute mediastinitis is usually caused by bacteria and is most often due to perforation of the esophagus. As the infection can progress rapidly, this is considered a serious condition.

Chronic sclerosing (or fibrosing) mediastinitis, while potentially serious, is caused by a long-standing inflammation of the mediastinum, leading to growth of acellular collagen and fibrous tissue within the chest and around the central vessels and airways. It has a different cause, treatment, and prognosis than acute infectious mediastinitis.

Space infections: Pretracheal space – lies anterior to trachea. Pretracheal space infection leads to mediastinitis. Here, the fascia fuses with the pericardium and the parietal pleura, which explains the occurrence of empyema and pericardial effusion in mediastinitis. However, infectious of other spaces can also lead to mediastinitis.

Symptoms

Acute

Acute mediastinitis is an infectious process and can cause fever, chills, tachycardia. Pain can occur with mediastinitis but the location of the pain depends on which part of the mediastinum is involved. When the upper mediastinum is involved, the pain is typically retro-sternal pain. When the lower mediastinum is involved, pain can be located between in the scapulae and radiate around to the chest. [2]

Chronic

Symptoms depend on what organs of the mediastinum the disease is affecting. They might be caused by a constricted airway, constricted esophagus, or constricted blood vessels. Symptoms also depend on how much fibrosis has occurred. There may be cough, shortness of breath, coughing up blood, pain in the chest, and difficulty in swallowing. [3]

Causes

Mediastinum Anatomy Mediastinum.png
Mediastinum Anatomy

Acute

CT scan of a patient with Descending Necrotizing Mediastinitis. CT scan of a patient with Descending Necrotizing Mediastinitis.jpg
CT scan of a patient with Descending Necrotizing Mediastinitis.

Esophageal perforation, a form of direct contamination, accounts for 90% of acute mediastinal infections. [1] Esophageal perforation can arise from vomiting, incidental trauma from a procedure or operation, external trauma, ingestion of corrosive substances, malignancy, or other esophageal disease. [1]

Other causes of acute mediastinitis include infection secondary to cervical disease which arises from dental procedures, skin infections of the neck, neck trauma, or neck procedures. [1]

Descending necrotizing mediastinitis (DNM) was first described by Herman E. Pearse Jr., M.D. in 1938 and he stated, "the term 'mediastinitis' means little unless qualified by a description of its type and kind." [4] Although Descending Necrotizing Mediastinitis is an acute mediastinitis, it is distinct because it does not originate from structures within the mediastinum. Therefore, the term Descending Necrotizing Mediastinitis implies that the infection of the mediastinum originated from a primary site in the head or neck and descended through fascial spaces into the mediastinum.[ citation needed ]

Though rare in developed countries, acute mediastinitis can be caused by inhalation of bacterial spores such as Anthrax. Historically, this infection was referred to as Wool-sorter's Disease. In the lungs, spores can spread via lymphatics to mediastinal lymph nodes, where the mature rods can release exotoxins promoting edema and tissue necrosis. [5] Clinically, persons infected with anthrax can develop a hemorrhagic mediastinitis, which manifests as acute pulmonary hemorrhage and meningitis. [5] Hallmark finding of disease is a widened mediastinum visualized on chest x-ray. Once clinical symptoms of anthrax induced mediastinitis appear, disease is nearly 100% fatal. Individuals with known exposure to spores may be treated prophylactically with antibiotics (fluoroquinolones or tetracycline) to prevent disease progression.

Chronic

There are two types of fibrosing mediastinitis: granulomatous and non-granulomatous. Granulomatous mediastinitis is due to a granulomatous process of the mediastinal lymph nodes leading to fibrosis and chronic abscesses in the mediastinum. The most common causes are histoplasmosis and tuberculosis infections. Non-granulomatous fibrosing mediastinitis is caused by an idiopathic reaction to drugs and radiation therapy. [6] Autoimmune disease and Behcet's disease are also causes. [3]

Etiology

An observational retrospective study of 17 patients diagnosed with DNM found that the infections most often originated from neck infections including tonsillar abscess, pharyngitis, and epiglottitis. The study also found that most infections are poly-microbial. [7] Often the culprits are usually Gram-positive bacteria and anaerobes, though rarely, Gram-negative bacteria are also present. This severe form represents 20% of acute mediastinitis cases. [8]

Diagnosis

Acute

Acute mediastinitis can be confirmed by contrast x-rays since most cases of acute mediastinitis are due to esophageal perforation. Other studies that can be used include endoscopic visualization, Chest CT scan with oral and intravenous contrast.[ citation needed ]

With regards to CT Imaging, the extent of involvement of the mediastinum can be evaluated. Therefore, acute mediastinitis can be classified into three categories: [9]

  1. diffuse mediastinitis
  2. isolated mediastinal abscess
  3. mediastinitis or mediastinal abscess complicated by empyema or subphrenic abscess.

Chronic

Most cases of granulomatous mediastinitis (75%) are incidentally found on chest x-rays which show a mediastinal mass, or widening of the mediastinum. [6]

Treatment

Treatment for acute mediastinitis usually involves aggressive intravenous antibiotic therapy and hydration. If discrete fluid collections or grossly infected tissue have formed (such as abscesses), they may have to be surgically drained or debrided. [1]

Treatment for DNM usually requires an operation to remove and drain infected necrotic tissue. Broad spectrum intravenous antibiotics are also given to treat the infection. Patients are typically managed in the intensive care unit due to the severity of the disease. [7]

Treatment for chronic fibrosing mediastinitis is somewhat controversial, and may include steroids or surgical decompression of affected vessels.[ citation needed ]

Prognosis

Fibrosing mediastinitis can lead to entrapment of mediastinal structures. The mortality of DNM ranges from 10 to 40% due to sepsis and multi-organ failure if not recognized and intervened upon early.[ citation needed ]

Related Research Articles

<span class="mw-page-title-main">Pleural cavity</span> Thin fluid-filled space between the two pulmonary pleurae (visceral and parietal) of each lung

The pleural cavity, pleural space, or interpleural space is the potential space between the pleurae of the pleural sac that surrounds each lung. A small amount of serous pleural fluid is maintained in the pleural cavity to enable lubrication between the membranes, and also to create a pressure gradient.

<span class="mw-page-title-main">Necrotizing gingivitis</span> Non-contagious, painful bacterial infection of the gums

Necrotizing gingivitis (NG) is a common, non-contagious infection of the gums with sudden onset. The main features are painful, bleeding gums, and ulceration of inter-dental papillae. This disease, along with necrotizing periodontitis (NP) and necrotizing stomatitis, is classified as a necrotizing periodontal disease, one of the three general types of gum disease caused by inflammation of the gums (periodontitis).

<span class="mw-page-title-main">Necrotizing fasciitis</span> Infection that results in the death of the bodys soft tissue

Necrotizing fasciitis (NF), also known as flesh-eating disease, is a bacterial infection that results in the death of parts of the body's soft tissue. It is a severe disease of sudden onset that spreads rapidly. Symptoms usually include red or purple skin in the affected area, severe pain, fever, and vomiting. The most commonly affected areas are the limbs and perineum.

<span class="mw-page-title-main">Granuloma</span> Aggregation of macrophages in response to chronic inflammation

A granuloma is an aggregation of macrophages that forms in response to chronic inflammation. This occurs when the immune system attempts to isolate foreign substances that it is otherwise unable to eliminate. Such substances include infectious organisms including bacteria and fungi, as well as other materials such as foreign objects, keratin, and suture fragments.

<span class="mw-page-title-main">Atelectasis</span> Collapse or closure of a lung resulting in reduced or absent gas exchange

Atelectasis is the collapse or closure of a lung resulting in reduced or absent gas exchange. It is usually unilateral, affecting part or all of one lung. It is a condition where the alveoli are deflated down to little or no volume, as distinct from pulmonary consolidation, in which they are filled with liquid. It is often called a collapsed lung, although that term may also refer to pneumothorax.

<span class="mw-page-title-main">Superior vena cava syndrome</span> Group of symptoms caused by obstruction of the superior vena cava

Superior vena cava syndrome (SVCS), is a group of symptoms caused by obstruction of the superior vena cava ("SVC"), a short, wide vessel carrying circulating blood into the heart. The majority of cases are caused by malignant tumors within the mediastinum, most commonly lung cancer and non-Hodgkin's lymphoma, directly compressing or invading the SVC wall. Non-malignant causes are increasing in prevalence due to expanding use of intravascular devices, which can result in thrombosis. Other non-malignant causes include benign mediastinal tumors, aortic aneurysm, infections, and fibrosing mediastinitis.

<span class="mw-page-title-main">Mediastinum</span> Central part of the thoracic cavity

The mediastinum is the central compartment of the thoracic cavity. Surrounded by loose connective tissue, it is an undelineated region that contains a group of structures within the thorax, namely the heart and its vessels, the esophagus, the trachea, the phrenic and cardiac nerves, the thoracic duct, the thymus and the lymph nodes of the central chest.

<span class="mw-page-title-main">Lung abscess</span> Medical condition

Lung abscess is a type of liquefactive necrosis of the lung tissue and formation of cavities containing necrotic debris or fluid caused by microbial infection.

<span class="mw-page-title-main">Esophageal rupture</span> Medical condition

Esophageal rupture is a rupture of the esophageal wall. Iatrogenic causes account for approximately 56% of esophageal perforations, usually due to medical instrumentation such as an endoscopy or paraesophageal surgery. In contrast, the term Boerhaave syndrome is reserved for the 10% of esophageal perforations which occur due to vomiting.

<span class="mw-page-title-main">Pancreatic fistula</span> Medical condition

A pancreatic fistula is an abnormal communication between the pancreas and other organs due to leakage of pancreatic secretions from damaged pancreatic ducts. An external pancreatic fistula is one that communicates with the skin, and is also known as a pancreaticocutaneous fistula, whereas an internal pancreatic fistula communicates with other internal organs or spaces. Pancreatic fistulas can be caused by pancreatic disease, trauma, or surgery.

<i>Peptostreptococcus</i> Genus of bacteria

Peptostreptococcus is a genus of anaerobic, Gram-positive, non-spore forming bacteria. The cells are small, spherical, and can occur in short chains, in pairs or individually. They typically move using cilia. Peptostreptococcus are slow-growing bacteria with increasing resistance to antimicrobial drugs. Peptostreptococcus is a normal inhabitant of the healthy lower reproductive tract of women.

<span class="mw-page-title-main">Pericoronitis</span> Inflammation of the soft tissues surrounding the crown of a partially erupted tooth

Pericoronitis is inflammation of the soft tissues surrounding the crown of a partially erupted tooth, including the gingiva (gums) and the dental follicle. The soft tissue covering a partially erupted tooth is known as an operculum, an area which can be difficult to access with normal oral hygiene methods. The hyponym operculitis technically refers to inflammation of the operculum alone.

Mediastinal germ cell tumors are tumors that derive from germ cell rest remnants in the mediastinum. Germ cell tumors most commonly occur in the gonad but occasionally elsewhere.

<span class="mw-page-title-main">Dental abscess</span> Medical condition

A dental abscess is a localized collection of pus associated with a tooth. The most common type of dental abscess is a periapical abscess, and the second most common is a periodontal abscess. In a periapical abscess, usually the origin is a bacterial infection that has accumulated in the soft, often dead, pulp of the tooth. This can be caused by tooth decay, broken teeth or extensive periodontal disease. A failed root canal treatment may also create a similar abscess.

<span class="mw-page-title-main">Bird fancier's lung</span> Type of hypersensitivity pneumonitis

Bird fancier's lung (BFL), also known as bird breeder's lung, is a type of hypersensitivity pneumonitis. It can cause shortness of breath, fever, dry cough, chest pain, anorexia and weight loss, fatigue, and progressive pulmonary fibrosis. It is triggered by exposure to avian proteins present in the dry dust of droppings or feathers of a variety of birds. The lungs become inflamed, with granuloma formation. It mostly affects people who work with birds or own many birds.

Mouth infections, also known as oral infections, are a group of infections that occur around the oral cavity. They include dental infection, dental abscess, and Ludwig's angina. Mouth infections typically originate from dental caries at the root of molars and premolars that spread to adjacent structures. In otherwise healthy patients, removing the offending tooth to allow drainage will usually resolve the infection. In cases that spread to adjacent structures or in immunocompromised patients, surgical drainage and systemic antibiotics may be required in addition to tooth extraction. Since bacteria that normally reside in the oral cavity cause mouth infections, proper dental hygiene can prevent most cases of infection. As such, mouth infections are more common in populations with poor access to dental care or populations with health-related behaviors that damage one's teeth and oral mucosa. This is a common problem, representing nearly 36% of all encounters within the emergency department related to dental conditions.

<span class="mw-page-title-main">Subcutaneous emphysema</span> Medical condition

Subcutaneous emphysema occurs when gas or air accumulates and seeps under the skin, where normally no gas should be present. Subcutaneous refers to the subcutaneous tissue, and emphysema refers to trapped air pockets. Since the air generally comes from the chest cavity, subcutaneous emphysema usually occurs around the upper torso, such as on the chest, neck, face, axillae and arms, where it is able to travel with little resistance along the loose connective tissue within the superficial fascia. Subcutaneous emphysema has a characteristic crackling-feel to the touch, a sensation that has been described as similar to touching warm Rice Krispies. This sensation of air under the skin is known as subcutaneous crepitation, a form of crepitus.

Anaerobic infections are caused by anaerobic bacteria. Obligately anaerobic bacteria do not grow on solid media in room air ; facultatively anaerobic bacteria can grow in the presence or absence of air. Microaerophilic bacteria do not grow at all aerobically or grow poorly, but grow better under 10% carbon dioxide or anaerobically. Anaerobic bacteria can be divided into strict anaerobes that can not grow in the presence of more than 0.5% oxygen and moderate anaerobic bacteria that are able of growing between 2 and 8% oxygen. Anaerobic bacteria usually do not possess catalase, but some can generate superoxide dismutase which protects them from oxygen.

<span class="mw-page-title-main">Pulmonary pleurae</span> Serous membrane that lines the wall of the thoracic cavity and the surface of the lung

The pulmonary pleurae are the two opposing layers of serous membrane overlying the lungs and the inside of the surrounding chest walls.

References

  1. 1 2 3 4 5 Deatrick, K. Barrett; Long, Jason; Chang, Andrew C. (2015), Doherty, Gerard M. (ed.), "Thoracic Wall, Pleura, Mediastinum, & Lung", CURRENT Diagnosis & Treatment: Surgery (14 ed.), McGraw-Hill Education, retrieved 2018-12-14
  2. Goodwin, R.A. (1998). Pulmonary Disease and Disorders (3rd ed.). New York: McGraw-Hill. pp. 1479–1490.
  3. 1 2 "Fibrosing mediastinitis | Genetic and Rare Diseases Information Center (GARD) – an NCATS Program". rarediseases.info.nih.gov. Archived from the original on 2019-02-01. Retrieved 2019-01-31.
  4. Pearse, Herman E. (1938-10-01). "Mediastinitis Following Cervical Suppuration". Annals of Surgery. 108 (4): 588–611. doi:10.1097/00000658-193810000-00009. ISSN   0003-4932. PMC   1387034 . PMID   17857255.
  5. 1 2 Tournier, Jean-Nicolas (2009), "Pulmonary Anthrax", in Lang, Florian (ed.), Encyclopedia of Molecular Mechanisms of Disease, Berlin, Heidelberg: Springer, pp. 1756–1758, doi:10.1007/978-3-540-29676-8_3234, ISBN   978-3-540-29676-8 , retrieved 2021-05-17
  6. 1 2 Jain, Neeraj; Chauhan, Udit; Puri, Sunil Kumar; Agrawal, Sachin; Garg, Lalit (2015-11-16). "Fibrosing mediastinitis: when to suspect and how to evaluate?". BJR Case Reports. 2 (1): 20150274. doi:10.1259/bjrcr.20150274. PMC   6195926 . PMID   30364448.
  7. 1 2 Schmid, Ralph A.; Wiegand, Jan; Caversaccio, Marco; Hoksch, Beatrix; Kocher, Gregor J. (2012-10-01). "Diffuse descending necrotizing mediastinitis: surgical therapy and outcome in a single-centre series". European Journal of Cardio-Thoracic Surgery. 42 (4): e66–e72. doi: 10.1093/ejcts/ezs385 . ISSN   1010-7940. PMID   22761501.
  8. Pota, Vincenzo; Passavanti, Maria Beatrice; Sansone, Pasquale; Pace, Maria Caterina; Peluso, Filomena; Fiorelli, Alfonso; Aurilio, Caterina (2018-03-03). "Septic shock from descending necrotizing mediastinitis – combined treatment with IgM-enriched immunoglobulin preparation and direct polymyxin B hemoperfusion: a case report". Journal of Medical Case Reports. 12 (1): 55. doi: 10.1186/s13256-018-1611-5 . ISSN   1752-1947. PMC   5834850 . PMID   29499757.
  9. Carrol, Clark L.; Jeffrey, R. Brooke; Federle, Michael P.; Vernacchia, Fred S. (May 1987). "CT Evaluation of Mediastinal Infections". Journal of Computer Assisted Tomography. 11 (3): 449–454. doi:10.1097/00004728-198705000-00015. ISSN   0363-8715. PMID   3571587.