Acute mediastinitis. What to do when the cause is nonsurgical

Critical care transesophageal endosonography and guided fine-needle aspiration for diagnosis and management of posterior mediastinitis

BACKGROUND

Acute mediastinitis is a serious complication; it occurs after esophageal perforation and thoracic surgery and is rarely due to infections. Clinical and computed tomographic scan signs may be nonspecific, especially in postoperative patients.

DESIGN

We prospectively evaluated the value of transesophageal endosonography with guided fine-needle aspiration in the diagnosis and identification of etiologic agents in critically ill patients with suspected posterior mediastinitis.

SETTING

University hospital.

PATIENTS AND METHODS

Transesophageal endosonography/fine-needle aspiration was performed at the bedside in the intensive care unit with a Pentax 34UX echo-endoscope and a portable Hitachi console (EUB 525). Eighteen patients with clinically suspected mediastinitis were examined with intensive care team support.

RESULTS

Computed tomography was performed before transesophageal endosonography in all 18 patients and was inconclusive in 9. Transesophageal endosonography detected mediastinal lesions in 16 (89%) of 18 patients and was more accurately diagnostic than computed tomography (p =.0082). Fifteen patients had undergone surgery (11 esophagectomy, 1 other esophageal surgery, 1 head/neck cancer surgery, 1 complication after dilatational tracheostomy, and 1 with intervention after polytrauma). Three patients were suspected to have nonpostoperative mediastinitis. In 16 patients, infectious organisms were detected (bacterial, n = 14; fungal, n = 1; tuberculosis, n = 1). Culture and sensitivity of transesophageal endosonography/fine-needle aspiration specimens led to appropriate drug therapy. In two patients, methicillin-resistant Staphylococcus aureus was detected, leading to isolation care. Twelve patients improved; six died. Of the two patients in whom transesophageal endosonography did not detect a mediastinitis, one was false negative on autopsy. There were no complications.

CONCLUSION

Bedside transesophageal endosonography/fine-needle aspiration of posterior mediastinal lesions in critically ill patients was an effective and relatively noninvasive way to detect mediastinitis and provide material to identify the etiologic agent. It was particularly useful in postesophagectomy patients.

Acute mediastinitis due to Rhodococcus equi in a patient with human immunodeficiency virus infection

A patient with human immunodeficiency virus infection developed anterior mediastinitis during antibiotic treatment for empyema due to Rhodococcus equi. This is the first reported case of infection with this organism in this setting. Despite an adequate course of therapy and maintenance treatment with antibiotics to which the isolate of Rhodococcus equi was susceptible in vitro, the patient experienced relapse of the infection into the mediastinum. Clinicians should consider this complication when Rhodococcus equi is present in pleural effusions.

Broncho-mediastinal fistula following perforation of the oesophagus

We present a 63-year old female with mediastinitis following an esophageal perforation, possibly favoured by an oesophageal motility-disorder and the use of non-steroidal anti-inflammatory drugs, who developed a broncho-mediastinal fistula in the left main bronchus. She was successfully treated with intravenous antibiotics, a cervical oesophagostomy and secondary isoperistaltic coloplasty.