A 31-year-old male, with no personal history of interest, who came to the emergency department for presenting significant pain and inflammation in the left cervical region and back pain of several days of evolution, which increases with the associated respiratory movements,
He was admitted to the maxillofacial surgery service after 3 days of treatment for acute pharyngitis and submaxillitis with severe odynophagia and dysthermia.
Physical examination determines that the pharynx and tonsils are hyperemic.
In addition, a warm tumor is observed in the left submandibular region, and the right submandibular area is painful to fixation.
Examination of the neck revealed bilateral laterocervical adenopathies with decreased vesicular murmur in the right lower hemithorax on auscultation.
Along with these signs, the patient presents asthenia, fever, dyspnea, tachypnea and halitosis.
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The chest X-ray showed bilateral pleural effusion, so right pleural drainage was performed by the thoracic surgery service, with abundant purulent material (600 ml), and the initial treatment of pleural fibrinolysis was initiated.
Pleural fluid culture was positive for Gemella spp. and Streptococcus pyogenes, and initial blood cultures were positive for both germs.
As for the treatment, since the admission to the emergency room he was prescribed antibiotic therapy with amoxicillin-clavulanic acid, which did not present fever and important deterioration of the clinical picture after several days of intravenous treatment, because the syndrome persisted
The worsening of symptoms intensified analytical studies and imaging techniques, along with the modification of antibiotic therapy (piperacillin-ta fluconazole, daptomycin, amikacin).
A cervicothoracic computed tomography (CT) was performed, in which a multiloculated mediastinal collection was observed, with air bubbles inside, extending from the diaphragm with bilateral pleural effusion to the prethyroid region.
Bilateral compressive atelectasis was also observed.
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With these findings it was decided to perform an urgent cystectomy for diagnosis of acute descending necrotizing colitis, in which the thoracic surgeons approached the anterior mediastinum, with abundant malaollient and green suppuration.
Mediastinal dissection was thought to originate from the neck, as its mobilization and compression caused the appearance of more purulent fluid, due to the fact that left cervical exploration was performed using a cervicotomy approach.
The suppuration at the posterior border of the loop was greater after performing this incision and it was also observed the partial necrosis of the left internal jugular vein, which occurred at its ligation.
The patient was successfully treated with antibiotics and corticoids, although her improvement was slow, with disappearance of fever, decrease in leukocytosis and satisfactory clinical controls and discharge after 3 weeks of treatment with antibiotics and corticosteroids
