Fatal case of descending necrotising mediastinitis.

Sato R, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2017-221050 Description A 56-year-old man presented with a 4-day history of fever and sore throat followed by 1 day of wheezing. On examination, he appeared in acute distress. The blood pressure was 129/76 mm Hg, the pulse was 88 per min, the respiratory rate was 22 per min and the temperature was 38.2°C. Auscultation over the upper airway area noted stridor. Chest radiograph showed tracheal stenosis and air along the aorta (figure 1). At the emergency department, he developed respiratory arrest, and the trachea was incubated. CT scan with intravenous contrast showed a space-occupying lesion behind the pharynx and mediastinum emphysema (figure 2). A diagnosis of retropharyngeal abscess with descending necrotising mediastinitis was made. Despite antimicrobial therapy in intensive care, he developed septic shock and died on day 4 after the admission. Patients with retropharyngeal abscess usually have fever, sore throat, odynophagia, drooling and fatigue with dyspnoea and stridor mimicking wheezing in severe cases. Images of retropharyngeal abscess could show the narrowing of upper airway and the space-occupying lesion with ring enhancement in the retropharyngeal space by contrast CT scan. Wheezing history in this patient was probably imitated by stridor from upper airway compromise. Infections in retropharyngeal space could quickly spread down to mediastinum and cause descending necrotising mediastinitis.