Background: Acute mediastinitis is still associated with a high morbidity and mortality. Mediastinitis secondary to esophageal perforation is a rare but potentially life-threatening condition. Case presentation: This report aims to present an acute mediastinitis case, in a 54-year-old healthy female patient, which originated from an intrathoracic esophageal perforation with swallowing of duck bone that confirmed by computed tomography of the chest. The patient was successfully treated by an emergency left thoracotomy, effective surgical drainage and aggressive debridement of the affected mediastinal compartments, primitive repair of perforated esophagus with intercostal muscle flap, decompressive gastrostomy and jejunostomy for feeding. Post-operatively, the patient was benefited from broad-spectrum antibiotics, intensive care and resuscitation associated with a close follow-up consequence. Results: Mediastinitis was well-controlled. Post interventional computed tomography scan with hydro-soluble contrast ingestion showed no extraluminal leak and good integrity of esophagus. The patient restored normally oral feeding without any complications and was discharged after 24 days of hospitalization without any sequelae. Conclusions: Early diagnosis is critical for expediting the choice of an optimal treatment strategy and plays an important role in improving mortality from acute mediastinitis following perforated esophagus. Besides intensive care and resuscitation, we advocate an emergency thoracic surgery for cases with established mediastinitis following intrathoracic esophageal perforation.