Case Study
Ascending necrotizing mediastinitis secondary to emphysematous pyelonephritis
Asian Cardiovascular & Thoracic Annals 2014, Vol. 22(7) 869–871 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313495860 aan.sagepub.com
Walid Leonardo Dajer-Fadel, Martha Pichardo-Gonza´lez, Sandra Estrada-Ramos, Damia´n Palafox, Francisco Pascual Navarro-Reynoso and Rube´n Argu¨ero-Sa´nchez
Abstract Mediastinal infections usually originate from postoperative complications or in a descending manner from a cervical infectious process; few reports have emerged describing an ascending trajectory. A 56-year-old woman with a Huang class 1 left emphysematous pyelonephritis was referred due to a progression of an ascending necrotizing mediastinitis. A left posterolateral thoracotomy was performed, drainage and thorough lavage were carried out with a successful outcome. We believe this is the first reported case of ascending necrotizing mediastinitis secondary to an emphysematous renal infection.
Keywords Emphysema, mediastinitis, mediastinum, pyelonephritis, thoracic surgical procedures
Introduction Acute mediastinitis is an infection that involves the connective tissue in the mediastinum.1 The best treatment is exploration and drainage of the pleural and mediastinal spaces, debridement, and tailored parenteral antibiotic therapy.2 Usually, it presents as a complication of cardiac surgery, and rarely due to cervical infections that progress to descending necrotizing mediastinitis. In this case, an ascending pattern was observed, secondary to emphysematous pyelonephritis. This is a serious infection that produces necrotizing tissue of the upper urinary tract with gas in the collecting system, renal parenchyma, or adjacent structures. Most of these patients are diabetic and likely to be complicated by a microbial infection.3 The extremely rare association of this disease and ascending necrotizing mediastinitis prompted this report, and to our knowledge, this is the first time it has been described in world literature.
Case report A 56-year-old woman with a 5-year history of type 2 diabetes mellitus and hypertension, with a
cholecystectomy performed 4 years earlier, arrived at the urology department due to clinical manifestation of class 1 left emphysematous pyelonephritis with gas in the collecting system, which included pain in the renal fossa area, dysuria, pollakiuria, urinary urgency, fever, a left positive Giordano sign, and thrombocytopenia. A double-J stent was placed in the left ureter, and intravenous clindamycin and ceftriaxone were administered without any significant improvement and a sustained leukocyte increase. Six days later, a left pleural effusion was observed, and thoracentesis results where compatible with exudate with an 85% predominance of neutrophils, for which oral levofloxacin 750 mg every 24 h as well as diuretics were administered. Despite the previous measures, tachypnea, dyspnea, and fever persisted, with a white blood cell
Department of Cardiothoracic Surgery, General Hospital of Mexico ‘‘Dr. Eduardo Liceaga’’, Mexico City, Mexico Corresponding author: Walid Leonardo Dajer-Fadel, Ave. Cuauhtemoc #403 ed.12 apt. 102. C.P. 06760, Distrito Federal, Me´xico. Email: [email protected]
870
Asian Cardiovascular & Thoracic Annals 22(7)
Figure 1. (a) Axial tomographic view demonstrating retrosternal gas (arrow) and bilateral pleural effusions (arrowheads). (b) Coronal tomographic reconstruction demonstrating a left pleural effusion with passive atelectasis and gas at the periphery of the superior vena cava (arrows), and purulent effusion with gas in the esophageal hiatus (arrowheads). (c) Axial pulmonary window where gas can be seen in the vicinity of the superior vena cava (arrows).
count of 21,000. Eight days later, imaging studies (Figure 1) showed signs of minimum bilateral pleural effusion, perivascular heterogeneity of adipose tissue, and gas at the level of the inferior vena cava. The patient was referred to the cardiothoracic surgery department, where a thoracotomy and drainage of the thoracic spaces were performed. During the postoperative period in the Intensive Respiratory Unit, she had an adequate evolution, and weaning from ventilator support was completed in the first 24 h. Respiratory, thermic, and hemodynamic parameters returned to baseline. A Foley catheter remained in position. Blood, urine, and mediastinal cultures showed growth of Candida and Escherichia coli with sensitivity to carbapenem, piperacillin and tazobactam, for which antibiotic treatment was tailored accordingly. The patient was transferred to the general ward on day 3 after the procedure. On postoperative days 6 and 8, the left and right chest tubes were withdrawn, respectively. Leukocytosis dropped to 16,000. She was discharged from hospital on day 16. After 3 months, she remains asymptomatic, afebrile, with a normal respiratory physical examination, with adequate follow-up in the Cardiothoracic Surgery and Urology Outpatient Clinics, where the Foley catheter was retrieved.
Discussion Ascending necrotizing mediastinitis is a rare presentation of mediastinal infection. Common etiologies of acute mediastinitis include postoperative infection, esophageal perforation, and descending necrotizing mediastinitis from the oral cavity or pharynx. All types of mediastinitis are serious and lethal conditions. The best treatment is a surgical resolution with drainage of the mediastinal spaces and pleural cavities and adjunct intravenous broad-spectrum antibiotics.4 In this case, clinical manifestations of ascending mediastinitis were sought due to a history of emphysematous pyelonephritis. This occurs most frequently in women, the majority are diabetic, and it is highly lethal
when secondary sepsis occurs. Conservative treatment is recommended for grades I and II, whereas grades III and IV should be treated with aggressive surgery, with a reported survival rate of 86.3%.5 This contrasts with our case where class I emphysematous pyelonephritis progressed to a septic state. Khaira and colleagues6 reported that percutaneous drainage can be a feasible alternative in the treatment plan, and concluded that shock, serum creatinine > 5.0 mg dL 1, and disseminated intravascular coagulopathy are poor prognostic factors. In this case, the condition migrated to the thoracic cavity. Fortunately, drainage of the mediastinum and pleural cavities were promptly undertaken in a patient who was practically cured of her renal infection. Gas migration from the retroperitoneal space to the mediastinum has been described before, which resolved with a nephrectomy and antibiotic therapy.7 This is the first case of ascending mediastinitis arising from emphysematous pyelonephritis, which was treated by drainage and lavage with antimicrobial therapy. The urologic and thoracic surgeons must have a high level of suspicion when encountering a patient with emphysematous pyelonephritis and persistent signs of sepsis, to allow a prompt evaluation and discard or diagnose ascending necrotizing mediastinitis to adopt a treatment plan. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest statement The authors declare that there is no conflict of interest.
References 1. Vural FS, Girdwood RW, Patel AR and Zigiriadis E. Descending mediastinitis. Asian Cardiovasc Thorac Ann 2012; 20: 304–307. 2. Fauci AS, Braunwald E and Kasper DL. Principios de Medicina Interna, 17th ed. Mexico City: Mc-Graw Hill Interamericana Editores, 20091568.
Dajer-Fadel et al. 3. Wan YL, Lee TY, Bullard MJ and Tsai CC. Acute gas producing bacterial renal infection: correlation between imaging findings and clinical outcome. Radiology 1996; 198: 433–438. 4. Corsten MJ, Shamji FM, Odell PF, et al. Optimal treatment of descending necrotising mediastinitis. Thorax 1997; 52: 702–708. 5. Fatima R, Jha R, Muthukrishnan J, et al. Emphysematous pyelonephritis: a single center study. Indian J Nephrol 2013; 23: 119–124.
871 6. Khaira A, Gupta A, Rana DS, Gupta A, Bhalla A and Khullar D. Retrospective analysis of clinical profile prognostic factors and outcomes of 19 patients of emphysematous pyelonephritis. Int Urol Nephrol 2009; 41: 959–966. 7. Wang YC, Wang JM, Chow YC, Chiu AW and Yang S. Pneumomediastinum and subcutaneous emphysema as the manifestation of emphysematous pyelonephritis. Int J Urol 2004; 11: 909–911.
Ascending necrotizing mediastinitis secondary to emphysematous pyelonephritis
Asian Cardiovascular & Thoracic Annals 2014, Vol. 22(7) 869–871 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313495860 aan.sagepub.com
Walid Leonardo Dajer-Fadel, Martha Pichardo-Gonza´lez, Sandra Estrada-Ramos, Damia´n Palafox, Francisco Pascual Navarro-Reynoso and Rube´n Argu¨ero-Sa´nchez
Abstract Mediastinal infections usually originate from postoperative complications or in a descending manner from a cervical infectious process; few reports have emerged describing an ascending trajectory. A 56-year-old woman with a Huang class 1 left emphysematous pyelonephritis was referred due to a progression of an ascending necrotizing mediastinitis. A left posterolateral thoracotomy was performed, drainage and thorough lavage were carried out with a successful outcome. We believe this is the first reported case of ascending necrotizing mediastinitis secondary to an emphysematous renal infection.
Keywords Emphysema, mediastinitis, mediastinum, pyelonephritis, thoracic surgical procedures
Introduction Acute mediastinitis is an infection that involves the connective tissue in the mediastinum.1 The best treatment is exploration and drainage of the pleural and mediastinal spaces, debridement, and tailored parenteral antibiotic therapy.2 Usually, it presents as a complication of cardiac surgery, and rarely due to cervical infections that progress to descending necrotizing mediastinitis. In this case, an ascending pattern was observed, secondary to emphysematous pyelonephritis. This is a serious infection that produces necrotizing tissue of the upper urinary tract with gas in the collecting system, renal parenchyma, or adjacent structures. Most of these patients are diabetic and likely to be complicated by a microbial infection.3 The extremely rare association of this disease and ascending necrotizing mediastinitis prompted this report, and to our knowledge, this is the first time it has been described in world literature.
Case report A 56-year-old woman with a 5-year history of type 2 diabetes mellitus and hypertension, with a
cholecystectomy performed 4 years earlier, arrived at the urology department due to clinical manifestation of class 1 left emphysematous pyelonephritis with gas in the collecting system, which included pain in the renal fossa area, dysuria, pollakiuria, urinary urgency, fever, a left positive Giordano sign, and thrombocytopenia. A double-J stent was placed in the left ureter, and intravenous clindamycin and ceftriaxone were administered without any significant improvement and a sustained leukocyte increase. Six days later, a left pleural effusion was observed, and thoracentesis results where compatible with exudate with an 85% predominance of neutrophils, for which oral levofloxacin 750 mg every 24 h as well as diuretics were administered. Despite the previous measures, tachypnea, dyspnea, and fever persisted, with a white blood cell
Department of Cardiothoracic Surgery, General Hospital of Mexico ‘‘Dr. Eduardo Liceaga’’, Mexico City, Mexico Corresponding author: Walid Leonardo Dajer-Fadel, Ave. Cuauhtemoc #403 ed.12 apt. 102. C.P. 06760, Distrito Federal, Me´xico. Email: [email protected]
870
Asian Cardiovascular & Thoracic Annals 22(7)
Figure 1. (a) Axial tomographic view demonstrating retrosternal gas (arrow) and bilateral pleural effusions (arrowheads). (b) Coronal tomographic reconstruction demonstrating a left pleural effusion with passive atelectasis and gas at the periphery of the superior vena cava (arrows), and purulent effusion with gas in the esophageal hiatus (arrowheads). (c) Axial pulmonary window where gas can be seen in the vicinity of the superior vena cava (arrows).
count of 21,000. Eight days later, imaging studies (Figure 1) showed signs of minimum bilateral pleural effusion, perivascular heterogeneity of adipose tissue, and gas at the level of the inferior vena cava. The patient was referred to the cardiothoracic surgery department, where a thoracotomy and drainage of the thoracic spaces were performed. During the postoperative period in the Intensive Respiratory Unit, she had an adequate evolution, and weaning from ventilator support was completed in the first 24 h. Respiratory, thermic, and hemodynamic parameters returned to baseline. A Foley catheter remained in position. Blood, urine, and mediastinal cultures showed growth of Candida and Escherichia coli with sensitivity to carbapenem, piperacillin and tazobactam, for which antibiotic treatment was tailored accordingly. The patient was transferred to the general ward on day 3 after the procedure. On postoperative days 6 and 8, the left and right chest tubes were withdrawn, respectively. Leukocytosis dropped to 16,000. She was discharged from hospital on day 16. After 3 months, she remains asymptomatic, afebrile, with a normal respiratory physical examination, with adequate follow-up in the Cardiothoracic Surgery and Urology Outpatient Clinics, where the Foley catheter was retrieved.
Discussion Ascending necrotizing mediastinitis is a rare presentation of mediastinal infection. Common etiologies of acute mediastinitis include postoperative infection, esophageal perforation, and descending necrotizing mediastinitis from the oral cavity or pharynx. All types of mediastinitis are serious and lethal conditions. The best treatment is a surgical resolution with drainage of the mediastinal spaces and pleural cavities and adjunct intravenous broad-spectrum antibiotics.4 In this case, clinical manifestations of ascending mediastinitis were sought due to a history of emphysematous pyelonephritis. This occurs most frequently in women, the majority are diabetic, and it is highly lethal
when secondary sepsis occurs. Conservative treatment is recommended for grades I and II, whereas grades III and IV should be treated with aggressive surgery, with a reported survival rate of 86.3%.5 This contrasts with our case where class I emphysematous pyelonephritis progressed to a septic state. Khaira and colleagues6 reported that percutaneous drainage can be a feasible alternative in the treatment plan, and concluded that shock, serum creatinine > 5.0 mg dL 1, and disseminated intravascular coagulopathy are poor prognostic factors. In this case, the condition migrated to the thoracic cavity. Fortunately, drainage of the mediastinum and pleural cavities were promptly undertaken in a patient who was practically cured of her renal infection. Gas migration from the retroperitoneal space to the mediastinum has been described before, which resolved with a nephrectomy and antibiotic therapy.7 This is the first case of ascending mediastinitis arising from emphysematous pyelonephritis, which was treated by drainage and lavage with antimicrobial therapy. The urologic and thoracic surgeons must have a high level of suspicion when encountering a patient with emphysematous pyelonephritis and persistent signs of sepsis, to allow a prompt evaluation and discard or diagnose ascending necrotizing mediastinitis to adopt a treatment plan. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest statement The authors declare that there is no conflict of interest.
References 1. Vural FS, Girdwood RW, Patel AR and Zigiriadis E. Descending mediastinitis. Asian Cardiovasc Thorac Ann 2012; 20: 304–307. 2. Fauci AS, Braunwald E and Kasper DL. Principios de Medicina Interna, 17th ed. Mexico City: Mc-Graw Hill Interamericana Editores, 20091568.
Dajer-Fadel et al. 3. Wan YL, Lee TY, Bullard MJ and Tsai CC. Acute gas producing bacterial renal infection: correlation between imaging findings and clinical outcome. Radiology 1996; 198: 433–438. 4. Corsten MJ, Shamji FM, Odell PF, et al. Optimal treatment of descending necrotising mediastinitis. Thorax 1997; 52: 702–708. 5. Fatima R, Jha R, Muthukrishnan J, et al. Emphysematous pyelonephritis: a single center study. Indian J Nephrol 2013; 23: 119–124.
871 6. Khaira A, Gupta A, Rana DS, Gupta A, Bhalla A and Khullar D. Retrospective analysis of clinical profile prognostic factors and outcomes of 19 patients of emphysematous pyelonephritis. Int Urol Nephrol 2009; 41: 959–966. 7. Wang YC, Wang JM, Chow YC, Chiu AW and Yang S. Pneumomediastinum and subcutaneous emphysema as the manifestation of emphysematous pyelonephritis. Int J Urol 2004; 11: 909–911.
