Diagnosis
Pus in the mediastinum.
Epidemiologic Risks
Usually trauma, post surgical, or esophageal perforation for a variety of reasons including foreign body ingestion (PubMed). I had one guy who perforated his esophagus from a tortilla chip.
Neck infections can track down into the mediastinum aka descending mediastinitis (PubMed)(PubMed).
Microbiology
Trauma and post operative tends to be S. aureus and S. epidermidis.
Esophageal perforation and head&neck infections tend towards mixed infections with viridans and other streptococci, Peptostreptococcus, Bacteroides, and oral anaerobes.
Occasionally actinomycosis will burrow into the mediastinum.
Fibrosing Mediastinitis, a complication of granulomatous mediastinal infection, can be from Histoplasmosis or Tuberculosis.
Empiric Therapy
Trauma and post operative: anti-staphylococcal therapy.
Esophageal perforation or head&neck infection: (penicillin G OR ampicillin PLUS metronidazole) OR (third generation cephalosporins PLUS metronidazole) OR (quinolone PLUS metronidazole) OR penicillin/beta-lactamase inhibitors OR clindamycin OR cefoxitin OR cefotetan.
Drain the pus, always drain the pus. It is often a surgical emergency.
Curious Cases
Relevant links to my Medscape blog
Last Update: 11/07/18.