Anterior
Mediastinal
Abscess
Complicating
Septic Arthritis
By A. Smith and N. Sinzobahamvya Harare, Zimbabwe l An 11-year-old boy with septic arthritis of both knees presented with an anterior mediastinal abscess extending suprasternally. This was drained through a suprasternal incision and the mediastinal cavity was intermittently irrigated with povidone iodine solution and packed with gauze. Staphy/ococcus aureus was the responsible organism. Antibiotic therapy comprised of cloxacillin and gentamycin. Recovery was uneventful. This is, most probably, the first report on an anterior mediastinal abscess complicating a distant septic arthritis. As for any infective mediastinitis, early diagnosis and aggressive treatment is mandatory for a patient’s survival. Copyright :?I1992 by W.B. Saunders Company INDEX WORDS: Arthritis, septic; mediastinal
abscess.
LL-DOCUMENTED complications of septic arthritis are bronchopneumonia, pericarditis, and meningitis. Rarer complications are hepatitis, Lyme’s syndrome, Guillain-Barre syndrome, and fistula formation.‘~’ This case presented with a complication that, to our knowledge, has not been documented before: an anterior mediastinal abscess.
w
CASE REPORT The patient was an 1l-year-old boy who presented with a history of having fallen 3 weeks previously, injuring his right knee. Two days after the injury. his right knee became swollen and more painful. He then developed a fever and generalized body weakness. Ten days after the injury he noticed a mass in the suprasternal region of the neck. This was associated with increasing dyspnoea. On examination. he was an ill-looking child, pyrexial (38.7”C), with peripheral edema. a weak pulse, distended neck veins, and a 3-cm tender hepatomegaly. His heart apex was in the 6th intercostal space, anterior axillary line, with barely audible heart sounds on auscultation. The respiration rate was 35 breathsimin. Both knees were swollen and tender, with the right knee being more inflammed than the left. There was a lobulated cystic mass in the neck (suprasternal and thyroid region), extending retrosternally. The mass was cool to touch. not tender, and disappeared on pressure. Clinically. the mass behaved like a cystic hygroma or a Iymphadcnoma. The chest x-ray showed an enlarged globular heart and a widened upper mediastinum due to a mass in the anterior superior mediastinum. X-rays of both knees showed soft tissue swelling more marked in the right knee. On echocardiography. a pericardial elfusion of 22 mm was demonstrated. Diagnosis of cardiac tamponnade and septic arthritis of both knees was made. We wondered whether there was a relationship between the mediastinal mass and the pericardial effusion. Pericardiocentesis was performed via the subxiphoid route to relieve the tamponnade and for bacteriology and cytology studies. The fluid obtained was serosanguinous. Culture and cytology were both negative. On needling the neck mass pus was aspirated. This abscess was opened via a suprasternal horizontal incision, and drained of its pus. The abscess cavity extended retrosternally in the anterior superior mediastinum. It was irrigated with povidone iodine solution and packed with gauze soaked in povidone iodine. Jo/ournalofPed/arricSurgery, Vol27, No
1
(January),
1992: pp 101.102
Culture of the pus from both the abscess and the right knee showed Staphylococcus uureus, and the child was treated with cloxacillin and gentamycin for 2 weeks. The child’s temperature settled after the right knee had been adequately drained via an arthrotomy. Recovery was uneventful.
DISCUSSION
Infective mediastinitis, with or without abscess formation, is usually associated with rupture or perforation of the esophagus or the tracheobronchial tree, penetrating wounds of the chest, leaks of esophageal anastomoses, or bacterial inoculation of the mediastinum at thoracotomy, in particular median sternotomy for cardiac surgery.’ It can be secondary to spread of a focal infection, such as neck infection, retropharyngeal abscess, osteomyelitis of the thoracic and cervical spine or the sternum, empyema thoracis, or purulent pericarditis. It has also been reported as a complication of septicemia.” Various chronic infections such as tuberculosis, actinomycosis, aspergillosis, and, rarely, syphilis may involve the mediastinum.‘-’ Suppuration is usual with actinomycosis and may be a feature of progressive tuberculous adenitis; either of these infections may extend to involve the sternum and chest wall, giving rise to local abscesses and persistent sinuses. Few anterior mediastinal abscesses have previously been reported. They were secondary to sternal osteomylitis or to chronic infections such as tuberculosis or histoplasmosis.“’ To our knowledge, this report is the first of an anterior mediastinal abscess secondary to a distant arthritis. The mechanism here most probably was septicemia, although the blood cultures were negative, the child being on massive antibiotic therapy. The presence of a sympathetic pericardial effusion has previously been reported in a case of retropharyngeal abscess, mediastinitis, and pleural effusion described by Calandra and Mackowiak.” Pericardiocentesis in such cases is mandatory to relieve the eventual tamponnade and to perform bacterial studies in order to treat accordingly. In particular, purulent paricarditis may complicate septic arthritis. particularly in African children.” Early diagnosis and aggressive treatment of medias-
From the Department of Thoracic and Cardioruscular Sqe~. Pariren~atwa Hospital, Harare, Zimbabwe. Address reprint requests to N. Sinzohaham,ya. MD. Parirenyutwa Hospital, PO Box 8036, Causeway, Harare, Zimhahwc. Copyright ~11992 by W.B. Saunders Comparq 0022..~468/9212701-00-78$03.0010 101
102
SMITH AND SINZOBAHAMVIA
tinal infections are of utmost importance to reduce the mortality, which varies between 10% and 74%.” The treatment comprises adequated antibiotic therapy and surgical debridement and drainage. Irrigation with antibiotics and povidone iodine solution is
well documented in the management of mediastinitis after cardiac surgery. In the case reported, intermittent irrigation with povidone iodine and packing rapidly controlled the infection and allowed “filling” of the abscess cavity within 12 days.
REFERENCES 1. McCarty DJ, Ormiste V: Arthritis and hepatitis B antigen positive hepatitis. Arch Intern Med 132:264-268, 1973 2. Bedell SE, Pastor BM, Cohen SI: Symptomatic high grade heart block in Lyme disease. Chest 79:236-237, 1981 3. Faraq SS, Gelles DB: Yersinia arthritis and Guillain-Barre syndrome. N Engl J Med 307:755,1982 4. Hernandez LA, Buchanan WW, Mathieu JP: Sindrome de Sjogren. Rev Esp Rheumat Enfam Osteoartic 1951-74, 1976 5. Basile F, Prieto I: Sternal dehiscence and mediastinitis after open heart surgery. Union Med Can 111:1069-1072,1982 6. Zaltzmann M, Kallenbach J, Hockman M, et al: Fatal intrathoracic sepsis associated with neck space infection. Thorax 38143-145, 1983 7. Chandrcharoensin C, Viranuvatti V: Tuberculous abscess of the retrosternal thyroid gland displacing the oesophagus. Diagn Imaging 50:29-31, 1981
8. Scadding FH: Diseases of the mediastinum, in Mann WN, Lessof MH (eds): Conybeare’s Textbook of Medicine (ed 15). London, England, Livingstone, 1970, p 590 9. Cohen DM, Goggans EA: Sclerosing mediastinitis and terminal valvular endocarditis caused by fungus suggestive of Aspergihs species. Am J Clin Pathol56:91-96, 1971 10. Schneider RD, Reid JD: Mediastinal histoplasmosis with abscess. Chest 671237.239, 1975 11. Calandra GB, Mackowiak PA: Retropharyngeal abscess, mediastinitis and pleural effusion complicating streptococcal facial erysipelas. South Med J 74:1031-1032, 1981 12. Sinzobahamvya N, Ikeogu MO: Purulent pericarditis. Arch Dis Child 62:696-699, 1987 13. Rutledge R, Applebaum RE, Kim BJ: Mediastinal infection after open heart surgery. Surgery 97:88-92. 1985
Mediastinal
Abscess
Complicating
Septic Arthritis
By A. Smith and N. Sinzobahamvya Harare, Zimbabwe l An 11-year-old boy with septic arthritis of both knees presented with an anterior mediastinal abscess extending suprasternally. This was drained through a suprasternal incision and the mediastinal cavity was intermittently irrigated with povidone iodine solution and packed with gauze. Staphy/ococcus aureus was the responsible organism. Antibiotic therapy comprised of cloxacillin and gentamycin. Recovery was uneventful. This is, most probably, the first report on an anterior mediastinal abscess complicating a distant septic arthritis. As for any infective mediastinitis, early diagnosis and aggressive treatment is mandatory for a patient’s survival. Copyright :?I1992 by W.B. Saunders Company INDEX WORDS: Arthritis, septic; mediastinal
abscess.
LL-DOCUMENTED complications of septic arthritis are bronchopneumonia, pericarditis, and meningitis. Rarer complications are hepatitis, Lyme’s syndrome, Guillain-Barre syndrome, and fistula formation.‘~’ This case presented with a complication that, to our knowledge, has not been documented before: an anterior mediastinal abscess.
w
CASE REPORT The patient was an 1l-year-old boy who presented with a history of having fallen 3 weeks previously, injuring his right knee. Two days after the injury. his right knee became swollen and more painful. He then developed a fever and generalized body weakness. Ten days after the injury he noticed a mass in the suprasternal region of the neck. This was associated with increasing dyspnoea. On examination. he was an ill-looking child, pyrexial (38.7”C), with peripheral edema. a weak pulse, distended neck veins, and a 3-cm tender hepatomegaly. His heart apex was in the 6th intercostal space, anterior axillary line, with barely audible heart sounds on auscultation. The respiration rate was 35 breathsimin. Both knees were swollen and tender, with the right knee being more inflammed than the left. There was a lobulated cystic mass in the neck (suprasternal and thyroid region), extending retrosternally. The mass was cool to touch. not tender, and disappeared on pressure. Clinically. the mass behaved like a cystic hygroma or a Iymphadcnoma. The chest x-ray showed an enlarged globular heart and a widened upper mediastinum due to a mass in the anterior superior mediastinum. X-rays of both knees showed soft tissue swelling more marked in the right knee. On echocardiography. a pericardial elfusion of 22 mm was demonstrated. Diagnosis of cardiac tamponnade and septic arthritis of both knees was made. We wondered whether there was a relationship between the mediastinal mass and the pericardial effusion. Pericardiocentesis was performed via the subxiphoid route to relieve the tamponnade and for bacteriology and cytology studies. The fluid obtained was serosanguinous. Culture and cytology were both negative. On needling the neck mass pus was aspirated. This abscess was opened via a suprasternal horizontal incision, and drained of its pus. The abscess cavity extended retrosternally in the anterior superior mediastinum. It was irrigated with povidone iodine solution and packed with gauze soaked in povidone iodine. Jo/ournalofPed/arricSurgery, Vol27, No
1
(January),
1992: pp 101.102
Culture of the pus from both the abscess and the right knee showed Staphylococcus uureus, and the child was treated with cloxacillin and gentamycin for 2 weeks. The child’s temperature settled after the right knee had been adequately drained via an arthrotomy. Recovery was uneventful.
DISCUSSION
Infective mediastinitis, with or without abscess formation, is usually associated with rupture or perforation of the esophagus or the tracheobronchial tree, penetrating wounds of the chest, leaks of esophageal anastomoses, or bacterial inoculation of the mediastinum at thoracotomy, in particular median sternotomy for cardiac surgery.’ It can be secondary to spread of a focal infection, such as neck infection, retropharyngeal abscess, osteomyelitis of the thoracic and cervical spine or the sternum, empyema thoracis, or purulent pericarditis. It has also been reported as a complication of septicemia.” Various chronic infections such as tuberculosis, actinomycosis, aspergillosis, and, rarely, syphilis may involve the mediastinum.‘-’ Suppuration is usual with actinomycosis and may be a feature of progressive tuberculous adenitis; either of these infections may extend to involve the sternum and chest wall, giving rise to local abscesses and persistent sinuses. Few anterior mediastinal abscesses have previously been reported. They were secondary to sternal osteomylitis or to chronic infections such as tuberculosis or histoplasmosis.“’ To our knowledge, this report is the first of an anterior mediastinal abscess secondary to a distant arthritis. The mechanism here most probably was septicemia, although the blood cultures were negative, the child being on massive antibiotic therapy. The presence of a sympathetic pericardial effusion has previously been reported in a case of retropharyngeal abscess, mediastinitis, and pleural effusion described by Calandra and Mackowiak.” Pericardiocentesis in such cases is mandatory to relieve the eventual tamponnade and to perform bacterial studies in order to treat accordingly. In particular, purulent paricarditis may complicate septic arthritis. particularly in African children.” Early diagnosis and aggressive treatment of medias-
From the Department of Thoracic and Cardioruscular Sqe~. Pariren~atwa Hospital, Harare, Zimbabwe. Address reprint requests to N. Sinzohaham,ya. MD. Parirenyutwa Hospital, PO Box 8036, Causeway, Harare, Zimhahwc. Copyright ~11992 by W.B. Saunders Comparq 0022..~468/9212701-00-78$03.0010 101
102
SMITH AND SINZOBAHAMVIA
tinal infections are of utmost importance to reduce the mortality, which varies between 10% and 74%.” The treatment comprises adequated antibiotic therapy and surgical debridement and drainage. Irrigation with antibiotics and povidone iodine solution is
well documented in the management of mediastinitis after cardiac surgery. In the case reported, intermittent irrigation with povidone iodine and packing rapidly controlled the infection and allowed “filling” of the abscess cavity within 12 days.
REFERENCES 1. McCarty DJ, Ormiste V: Arthritis and hepatitis B antigen positive hepatitis. Arch Intern Med 132:264-268, 1973 2. Bedell SE, Pastor BM, Cohen SI: Symptomatic high grade heart block in Lyme disease. Chest 79:236-237, 1981 3. Faraq SS, Gelles DB: Yersinia arthritis and Guillain-Barre syndrome. N Engl J Med 307:755,1982 4. Hernandez LA, Buchanan WW, Mathieu JP: Sindrome de Sjogren. Rev Esp Rheumat Enfam Osteoartic 1951-74, 1976 5. Basile F, Prieto I: Sternal dehiscence and mediastinitis after open heart surgery. Union Med Can 111:1069-1072,1982 6. Zaltzmann M, Kallenbach J, Hockman M, et al: Fatal intrathoracic sepsis associated with neck space infection. Thorax 38143-145, 1983 7. Chandrcharoensin C, Viranuvatti V: Tuberculous abscess of the retrosternal thyroid gland displacing the oesophagus. Diagn Imaging 50:29-31, 1981
8. Scadding FH: Diseases of the mediastinum, in Mann WN, Lessof MH (eds): Conybeare’s Textbook of Medicine (ed 15). London, England, Livingstone, 1970, p 590 9. Cohen DM, Goggans EA: Sclerosing mediastinitis and terminal valvular endocarditis caused by fungus suggestive of Aspergihs species. Am J Clin Pathol56:91-96, 1971 10. Schneider RD, Reid JD: Mediastinal histoplasmosis with abscess. Chest 671237.239, 1975 11. Calandra GB, Mackowiak PA: Retropharyngeal abscess, mediastinitis and pleural effusion complicating streptococcal facial erysipelas. South Med J 74:1031-1032, 1981 12. Sinzobahamvya N, Ikeogu MO: Purulent pericarditis. Arch Dis Child 62:696-699, 1987 13. Rutledge R, Applebaum RE, Kim BJ: Mediastinal infection after open heart surgery. Surgery 97:88-92. 1985
