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 postoperative: 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.