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An elderly woman presented with fever, sore throat, difficulty swallowing and substernal chest pain that radiated to her shoulder for 3 days. She was febrile (38.8°C), tachycardic (133 bpm), and hypotensive (85/54 mmHg). Physical exams revealed neck tenderness without lymphadenopathy and bulging of left pharyngeal wall. Laboratory exams revealed elevated both white blood cell count (19.25 K/μL) and C-reactive protein (16.19 mg/dL). Lateral X-ray of neck (figure 1) showed thickening of retropharyngeal soft tissue (arrow) and abnormal air accumulation in the anterior neck (arrowhead). A subsequent contrast-enhanced CT (figures 2⇓–4) confirmed the diagnosis of cervical necrotising fasciitis with descending necrotising mediastinitis. She received intravenous antibiotic treatment, transcervical incision and drainage, and urgent debridement by thoracoscopic approach. However, she died of severe sepsis at postoperative day 4.
Descending necrotising mediastinitis is a potentially lethal disease caused by downward spread of deep neck infection. The infection may be originated from pharyngeal or odontogenic infections. Despite the modern antibiotic treatment and surgical technique, it still being reported with a mortality rate of 15% in recent meta-analysis.1 Along with thorough history taking and physical exams, contrast-enhanced CT image was valuable for establishing the diagnosis. Prompt diagnosis with antibiotic treatment and urgent surgical intervention are crucial to improve survival.
Footnotes
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Contributors CYH and APHH were responsible for the drafting of the manuscript. CYH conducted a survey and submitted the study.
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Competing interests None.
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Provenance and peer review Not commissioned; internally peer reviewed.