Scholarly article on topic 'Anterior mediastinal abscess diagnosed in a young sumo wrestler after closed blunt chest trauma'

Anterior mediastinal abscess diagnosed in a young sumo wrestler after closed blunt chest trauma Academic research paper on "Clinical medicine"

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{"Mediastinal abscess" / " Staphylococcus aureus " / "Sumo wrestler" / "Chest trauma"}

Abstract of research paper on Clinical medicine, author of scientific article — Tatsuro Sassa, Ken-ichiro Kobayashi, Masayuki Ota, Takuya Washino, Mayu Hikone, et al.

Abstract Most mediastinal abscesses result from infections after thoracotomy, esophageal perforation or penetrating chest trauma. This disease is rarely caused by closed blunt chest trauma. All previously reported such cases after closed blunt chest trauma presented with hematoma and sternal osteomyelitis resulting from sternal fracture. Here we report a 15-year-old sumo wrestler who presented with an anterior mediastinal abscess without any mediastinal fracture. The mediastinal abscess resulted from the hematogenous spread of Staphylococcus aureus to a hematoma that might have been caused by a closed blunt chest trauma incurred during sumo wrestling exercises.

Academic research paper on topic "Anterior mediastinal abscess diagnosed in a young sumo wrestler after closed blunt chest trauma"

Chinese Journal of Traumatology 18 (2015) 360—362

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Chinese Journal of Traumatology

journal homepage: http://www.elsevier.com/locate/CJTEE

Case report

Anterior mediastinal abscess diagnosed in a young sumo wrestler after closed blunt chest trauma

Tatsuro Sassa, Ken-ichiro Kobayashi*, Masayuki Ota, Takuya Washino, Mayu Hikone, Naoya Sakamoto, Sentaro Iwabuchi, Mizuto Otsuji, Kenji Ohnishi

Department of Infectious Disease, Tokyo Metropolitan Bokutoh General Hospital, 4-23-15 kohtohbashi, Sumida City, Tokyo 130-0022, Japan

ARTICLE INFO

Article history:

Received 16 January 2015

Received in revised form

18 January 2015

Accepted 12 March 2015

Available online 17 December 2015

Keywords: Mediastinal abscess Staphylococcus aureus Sumo wrestler Chest trauma

ABSTRACT

Most mediastinal abscesses result from infections after thoracotomy, esophageal perforation or penetrating chest trauma. This disease is rarely caused by closed blunt chest trauma. All previously reported such cases after closed blunt chest trauma presented with hematoma and sternal osteomyelitis resulting from sternal fracture. Here we report a 15-year-old sumo wrestler who presented with an anterior mediastinal abscess without any mediastinal fracture. The mediastinal abscess resulted from the he-matogenous spread of Staphylococcus aureus to a hematoma that might have been caused by a closed blunt chest trauma incurred during sumo wrestling exercises.

© 2015 Daping Hospital and the Research Institute of Surgery of the Third Military Medical University.

Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license

(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

Mediastinal infection is serious and often fatal infection resulting from direct contamination, extension from an adjacent infection, or the hematogenous spread of infection. Closed blunt chest trauma can cause mediastinal abscess, but only in fewer than 10 cases reported previously.

If a closed blunt chest trauma causes a sternal fracture with an accompanying hematoma, the hematogenous spread of a pathogen to the hematoma may cause a mediastinal abscess. The case we report here demonstrates that an anterior chest hematoma caused by blunt chest trauma poses a risk of mediastinal abscess even when no sternal fracture can be observed.

2. Case report

A 15-year-old, previously healthy boy presented to our hospital with fever and anterior chest pain. He had no history of intravenous drug use or family history of medical problems and not took regular medications. Two months before admission had he

* Corresponding author. E-mail address: simr355@yahoo.co.jp (K.-i. Kobayashi).

Peer review under responsibility of Daping Hospital and the Research Institute of Surgery of the Third Military Medical University.

started group living and taking part in regular sumo wrestling exercises in a sumo stable. Many bruises and abrasions of the skin during the exercises were incurred. He began suffering from anterior chest pain and fever two weeks before admission to our hospital. A few days prior to admission, a local physician had diagnosed his condition as a fracture of the rib. He was admitted to our hospital with worsening anterior chest pain and persistent fever. On admission he had a height of 166 cm, body weight of 66 kg, blood pressure of 129/77 mmHg, heart rate of 96 beats/ min, respiration rate of 20 times/min, and body temperature of 37.4 °C. Auscultation revealed no murmur. His right sternal edge was mildly swollen with severe tenderness. No lacerations, rashes, or hemorrhagic macules were noted. Laboratory tests showed white blood cell count of 2.24 x 104/mL, hemoglobin concentration of 136 g/L, platelet count of 1.36 x 1011/L, hematocrit of 28.2%, total bilirubin of 0.07 mmol/L, alanine aminotransferase of 428 U/L; aminotransferase of 194 U/L, lactate dehydrogenase of 342 U/L and C-reactive protein of 223.0 mg/L. Chest X ray revealed no pleural fluid or pneumothorax. A computed tomography (CT) scan of the chest showed abscess formations from the right greater pectoral muscle to anterior mediastinum (Fig. 1). No fractures of the sternum or ribs were seen.

At three days after admission, mediastinoscopic debridement was performed. No sternotomy was performed for the approach. The sterni was lifted from the subxiphisternal side, the pericardial frontal face was exfoliated, and a mediastinoscope was used to

http://dx.doi.org/10.1016/j.cjtee.2015.12.002

1008-1275/© 2015 Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Fig. 1. A chest CT scan showed subcutaneous adipose tissue inflammation (red arrow) and an anterior mediastinal mass (red arrow).

approach the abscess cavity. No sternal body fracture was observed. Hematoma and abscess were observed around the dorsal side of the sternal body, with white pus flowing from the abscess (Fig. 3). Gram staining of the pus revealed gram-positive-cocci. Drainage tubes were placed in bilateral pleural cavities and in the cavity of the anterior mediastinal abscess. Samples of blood and fluid aspirated from the anterior mediastinal abscess were both positive for methicillin-sensitive Staphylococcus aureus (MSSA). Vancomycin was therefore switched to cefazolin. The clinical course progressed well with antibiotic treatment and drainage. The patient was discharged 28 days after admission.

3. Discussion

Diffusion-weighted magnetic resonance (MR) imaging showed

central high signal intensity, T1-weighted imaging showed intermediate signal intensity, and contrast-enhanced T1-weighted MR imaging showed ring enhancing mass lesions from the right greater pectoral muscle to anterior mediastinal mass encircling the sternum (Fig. 2). No valve disease or vegetation was evident on trans-

thoracic echocardiography. At two days after admission, blood culture was positive for coagulase-positive Staphylococcus. Vancomycin was administered intravenously.

This case underlines the importance of recognizing that closed blunt chest trauma can cause mediastinal abscess, even when no sternal fracture appears. Mediastinal abscess generally results

from: 1) direct contamination after cardiac surgery or esophageal perforation or penetrating chest trauma, 2) inoculation by hema-togenous spread, 3) extension from adjacent infections of the chest wall, head and neck or retroperitoneum. Direct contamination is the most common cause of mediastinal abscess.1

Closed blunt chest trauma rarely causes mediastinal abscess. To our knowledge, only 8 previous cases have been reported.2-7 All 8 cases presented with accompanying hematoma, and sternal osteomyelitis resulting from sternal fracture. The chest trauma was caused by motor vehicle accidents, possibly falls or blunt assaults in 3 cases, a bicycle accident in 1 case, cardiopulmonary resuscitation in 2 cases, and elbowing during a basketball game in 1 case. In most cases, hematoma formation around the fractured sternal body was identified as a secondary infection contracted by hematogenous spread of a pathogen.

In our case, hematoma from the right greater pectoral muscle to anterior mediastinum was identified as a site of secondary infection inoculated by MSSA. Because no sternal fracture was observed, the hematoma could have formed as a consequence of repetitive blunt chest traumas incurred during sumo exercise. In previous cases, the secondary hematogenous spread of organisms has led to the formation of abscesses in hematomas of the chest wall or greater pectoral muscle without accompanying fractures.8,9 While sternal fractures and osteomyelitis do not appear to be essential preconditions for the development of mediastinal abscess. We are confident that abscess cannot develop without preexisting hematoma and bacteremia.

S. aureus was the major causative organism in the previously reported cases of mediastinal abscess caused by closed chest blunt trauma. While the sources of the bacteremia were unknown in most cases; intravenous drug use or catheter-related blood stream infection were detected in some cases.

In our case, physical examination and echocardiography ruled out infective endocarditis, cellulitis and other sites' infection, etc. as possible sources of MSSA bacteremia. The patient denied intravenous drug use and was free of any risk factors, such as upper endoscopy or cardiac surgery before the infection. Although He had no lacerations on admission, we now suspect that MSSA entered the blood stream through superficial skin wounds incurred during sumo exercise.

The treatment of mediastinal abscess consists of the systemic administration of antibiotic and early surgical drainage. Six out of the eight previously reported cases of mediastinal abscess caused by closed blunt chest trauma underwent open surgical drainage with thoracotomy.2-5 The other two cases underwent closed drainage6 and surgical drainage by a procedure not described,7 respectively. Initially we considered thoracotomy by dissection of the sternal bones or intercostal site for our case. The patient, however, was free from because there was no complication such as sternal fracture or osteomyelitis and he strongly wished to

Fig. 2. Diffusion-weighted MR imaging showed central high signal intensity (A), ^-weighted imaging showed intermediate signal intensity (B), and contrast-enhanced ^-weighted MR imaging showed ring-enhancing mass lesions (C) in the right greater pectoral muscle and anterior mediastinal mass.

Fig. 3. Endoscopic view of drainage procedure, with white puss flowing from abscess (red arrow).

continue sumo wrestling. We therefore performed endoscopic drainage of mediastinal abscess, a method that minimized muscular damage.

In summary, closed chest blunt trauma without sternal fracture or sternal osteomyelitis can cause mediastinal abscess. Hematoma formation in the mediastinum and potential sources of bacteremia create opportunities for mediastinal abscess. Mediastinoscopic drainage from a subxiphoid is one alternative for surgical debridement.

References

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3. Cuschieri J, Kralovich KA, Patton JH, et al. Anterior mediastinal abscess after closed sternal fracture. J Trauma. 1999;47:551—554.

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