Acute Mediastinitis as a Complication of Epstein-Barr Virus

Abstract

Acute mediastinitis is a rare, potentially life-threatening condition that is most commonly seen as a complication of esophageal perforations or cardiac surgery. The term "descending necrotizing mediastinitis" (DNM) is used to describe oropharyngeal infections that spread to the mediastinum, most commonly following odontogenic infections, peritonsillar or retropharyngeal abscesses, cervical lymphadenitis, trauma, or endotracheal intubation. Infectious mononucleosis is another rare cause of DNM. The mortality of acute mediastinitis is high, while the mortality for DNM is even higher. Major determinants of mortality are delayed diagnosis and/or treatment. While DNM is seen infrequently, its severe nature makes it essential that emergency physicians consider the diagnosis in patients presenting with upper respiratory infections, chest pain, and systemic symptoms, and also in patients with a recent diagnosis of EBV, in order to mitigate a high rate of morbidity and mortality. RÉSUMÉLa médiastinite aiguë est une maladie rare, potentiellement mortelle, qui résulte la plupart du temps d'une perforation de l'oesophage ou d'une opération cardiaque. L'expression « médiastinite nécrosante descendante » (MND) fait référence aux infections oropharyngées, qui se propagent au médiastin; il s'agit en général d'infections odontogènes, de phlegmons périamygdaliens ou d'abcès rétropharyngiens, de lymphadé-nite cervicale, de traumas ou d'intubations endotrachéales. La mononucléose infectieuse donne rarement lieu à une MND. Si la mortalité attribuable à la médiastinite aiguë est élevée, celle attribuable à la MND l'est encore plus. Les principaux déterminants de la mortalité sont un retard dans la pose du diagnostic ou la mise en route du traitement. Bien que les cas de MND soient rares, la gravité de la maladie exige que les médecins d'urgence envisagent le diagnostic chez les patients présentant une infection des voies respiratoires supérieures, des douleurs thoraciques et des symptômes généraux ainsi que chez les patients chez qui une infection à virus Epstein-Barr a été diagnostiquée depuis peu, afin d'abaisser le taux élevé de morbidité et de mortalité. Keywords: EBV, Acute Necrotizing Mediastinitis, Descending Necrotizing Mediastinitis CASE REPORTA previously healthy 39-year-old male initially presented to the emergency department (ED) with an upper respiratory tract infection characterized by cough, nasal congestion, rhinorrhea, bilateral earache with drainage, sore throat, nausea and vomiting. On physical examination, he was found to have bilateral ear effusions and upper airway congestion. He had normal heart sounds and his lungs had equal and clear air entry bilaterally. He had a temperature of 37°C (98.6°F), a heart rate of 113 beats per minute, respiratory rate of 16 breaths per minute, blood pressure of 114/79 mm Hg, and an oxygen saturation of 98% on room air. His chest x-ray was normal. He was diagnosed with a suspected viral illness, likely influenza, and discharged home. Two days later, this patient returned...

Cervical necrotising fasciitis: a rare complication of infectious mononucleosis

“…Our patient displayed evidence of infection spreading into the upper mediastinum. Descending mediastinitis in patients with IM has been described in four previous cases 4. The proposed mechanism of spread is either through direct spread of a pharyngeal abscess through the prevertebral fascia into the mediastinum, or through septic thromboemboli, also known as Lemierre’s syndrome.…”

“…IM is generally a benign self-limited illness characterised by lymphadenopathy, fever and pharyngotonsillitis. Head and neck complications of IM are rare but have been described 2–5. Johnsen et al described a five percent rate of otolaryngological complications in patients admitted for IM 6.…”

Fulminant descending mediastinitis secondary to infectious mononucleosis

“…DM most commonly originates from odontogenic infection, retropharyngeal abscess, peritonsillar abscess or cervical lymphadenitis [ 1 ]. It is a very rare complication of IM, which has been reported only four times previously ( Table S1, Supplementary File ).…”

“…DM is a life-threatening condition with reported mortality rates between 5 and 40% [ 1 ]. All reported EBV-associated cases of DM were promptly recognized with early definitive surgical management which may explain the 100% survival rate observed.…”

“…Contiguous spread of oropharyngeal or cervical infection into the mediastinum is termed descending mediastinitis (DM). Bacteria from the oral microflora spread into the mediastinum along the three fascial pathways of the neck: pretracheal, lateropharyngeal and retropharyngeal [ 1 ]. DM can present as a wide clinical spectrum, ranging from subacute to fulminant, with extensive fascial necrosis, abscesses and severe sepsis.…”