Descending necrotizing mediastinitis caused by Streptococcus
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Descending necrotizing mediastinitis is a severe infection of the mediastinum. This syndrome manifests as fever and chest pain following cough and sputum production.

This disease has become generally uncommon since the introduction of antibiotic therapy decades ago. Early surgical mediastinal drainage is strongly recommended for DNM.

A 49-year-old woman presented with fever and a 14-day history of pneumonia. CT showed mediastinal abscesses with a giant calcified mediastinal lymph node (21 × 18 mm) and pneumonia. Bronchoscopy by EBUS-TBNA under general anesthesia was performed. The pathogen found in the puncture culture was Streptococcus constellatus, and antibiotics (mezlocillin/sulbactam 3.375 IVGTT q8h) was administered. A proximal right main bronchial neoplasm, suspected lung cancer, was found and conformed to inflammatory granuloma. A total of 22 months post-discharge the patient was clinically stable.

The endobronchial Ultrasound-Guided Transbronchial showed a circle low density shadow in mediastinum. EBUS-TBNA was done, whose model of puncture needle was Olympus 4022 with diameter of 22G and the max-length of 40 mm and suction foam-like purulent secretion of about 5 ml with 20cmH2O negative pressure. The operation lasted about half an hour. Subsequently culture of mediastinal abscess fluid yielded Streptococcus constellatus, which was sensitive to penicillin and ceftriaxone.

In this case, EBUS-TBNA was key element for timely diagnosis and immediate intervention; it is not only effective in diagnosing necrotizing mediastinitis, but also assists in prompt mediastinal abscess fluid evacuation and helps avoid thoracotomy, hence improving the chances of recovery and survival.