Acute Descending Mediastinitis: An Unusual Presentation

Descending necrotizing mediastinitis is believed to be a rare disease in an era where antibiotics have lowered the incidence of fulminant infections worldwide. Mediastinitis is the swelling and inflammation of the mediastinum, which is the central compartment of the thoracic cavity that contains the heart, thymus gland, parts of the esophagus, trachea, and other organs. Patients with acute descending mediastinitis can present with a wide spectrum of symptomatology including chills, high fever, tachycardia, dyspnea, nonproductive cough, retrosternal pain, hypotension, and Hamman sign. The deep neck infections found usually originate from infection at other primary sites, most often within the pharynx or oral cavity. It is commonly accepted that the cervical fascia is divided into three layers: the superficial, middle, and deep layers, and these layers divide the deep neck into multiple spaces. Invasion of the neck infections to surrounding tissues, including mediastinum, is limited due to enriched lymphatics that drain the area. Therefore, additional risk factors should interplay when the infections disseminate. Mediastinitis typically manifests as inflammation and swelling in the mediastinum, but our case was unique as the initial presentation was bilateral flank pain. Our goal is to raise awareness about this rare yet very serious complication.