Descending necrotizing mediastinitis after upper gastrointestinal endoscopy.

An 83−year−old man presented with a 2− week history of intermittent left−sided chest pain. His chest radiograph and elec− trocardiogram were unremarkable, and so upper gastrointestinal endoscopy was performed for screening purposes. The in− tubation and procedure were carried out without difficulty, although the patient gagged occasionally. There was no ob− vious evidence of a site of perforation. Shortly after endoscopy, the patient be− came distressed, complaining of diffuse cervical swelling and a severe sore throat. Examination at that time revealed subcu− taneous emphysema of the neck. He had a fever, dyspnea, and hypoxemia. His la− boratory results revealed a white blood cell count of 18 000/mm3 and a C−reactive protein level of 22.5 mg/dl. A chest radio− graph showed pneumomediastinum and subcutaneous emphysema. Cervical and thoracic computed tomographic scans re− vealed cervical necrotizing fasciitis and descending necrotizing mediastinitis (Figure 1).