CASE PRESENTATION

1
CASE PRESENTATION

• Dr Jasbir Chhabra
• SHO Anaesthetics
• Royal Preston Hospital

2
Case history

• 35 yr old man
• Presented to the A E with
• 1. feeling unwell( malaise) x 48 hrs
• 2. sore throat x 48 hrs
• 3. fever
• 4. difficulty swallowing x 12 hrs
• 5. stridor (progressively worsening) x 12
  hrs

3
Past history

• Bipolar affective disorder on lithium carbonate
• Alcohol abuse with liver damage
• Binge drinking over the 4 weeks
• No known drug allergies

4
Examination

• Grossly septic
• Temp 38.4
• Neck swollen anteriorly
• P/r 126/min
• BP of 70- 80 systolic

5
Initial management in AE

• Oxygen, IV access two 14 G, fluids
• Nebs
• Blood cultures
• Ceftriaxone 2gms IV
• Anaesthetist called for help

6
Further management

• Gas induction with halothane (consultant)
• Laryngoscopy revealed oedematous swollen larynx
  with partially inflammed epiglottis,most swelling
  at the level of the false vocal cords

7
Other interventions

• Central line and art line
• NG tube
• Bladder catheterized
• CXR
• Nor adrenaline started to improve MAP

8
Investigations of significance

• WCC 15.5,platelets 223
• ABG mixed metabolic and respiratory acidosis
  with lactate of 10 and base excess of -14,ph
  7.08,pCO2 6.94,pO2 13.6 on 100Oxygen
• CXR marked mediastinal widening

9

• CT Scan findings
• Marked mediastinitis extending from the level of
  pharynx down to the lower thorax
• Bilateral basal lung consolidation,
• No evidence of mediastinal gas suggestive of
  upper GI perforation

10
Further management

• Transferred to ITU, Sedated ventilated
• Clindamycin and Tazocin
• Inotropic support (triple strength norad)
• Blood cultures Gp A hemolytic streptococcus
• Laryngeal swab Gp A hemolytic streptococcus
• septic shock with renal failure Xigris
• Gastro oesophagoscopy to rule out perforation
• No collections in mediastinum so surgery ruled out

11
Outcome

• Patient gradually improved ,was weaned off and
  extubated
• Discharged within 15 days of presentation

12
DESCENDING NECROTIZING MEDIASTINITIS(DNM)

• Rare but most fatal mediastinal infection,
  mortality rates (30-70)
• Usually due to rupture oesophagus or cardiac
  surgery
• Rarely due to a severe oropharyngeal infection,
  then the term DNM, usually dental abscess, rarely
  due to a sore throat
• Striking malefemale ratio 101,young men 30-40s
• Mediastinitis usually is a mixed growth
  infection, wide antimicrobial coverage is
  required.

13
Mortality rates

• In 1938, during the preantibiotic era, Pearse
  studied 21 patients with descending necrotizing
  mediastinitis and reported that the mortality
  rate exceeded 50 (11 of 21 patients).
• In 1983, Estrera et al described 10 cases that
  they had followed between 1975 and 1981 and
  reported a mortality rate of 40.
• More recently, Freeman et al reviewed 96 cases
  that occurred between 1970 and 1999 and found
  that the mortality rate was 29.
• Xigris era !!!,not as yet reported

14
Key suspect early

• Most viral sore throats resolve in 24 to 48
  hours.
• Chest pain ,difficulty swallowing
• Early aggressive management early aggressive
  broad spectrum antibiotic therapy
• Surgery
• Cervicotomy alone superior mediastinal space
• Thoracotomy and drainage when mediastinal sepsis
  is more extensive.