Abstract Introduction Mediastinal abscess is a rare but life-threatening complication of esophageal perforation, typically occurring at anatomically weak points such as Killian’s triangle, the cricopharyngeal region, and the esophagogastric junction. Spontaneous perforation, such as Boerhaave’s Syndrome, accounts for 8-33% of cases; traumatic and malignant causes represent 17%. We present a case of a relatively healthy male with polymicrobial mediastinal abscess related to silent aspiration. Case A 77-year-old male, with a past medical history of hypertension, presented with three months of intermittent abdominal cramping associated with nausea and vomiting, despite empiric outpatient acid suppression therapy. He was afebrile on presentation, tachycardic to 110s, normotensive, and saturating 90% on room air. His laboratory work up was notable for white blood cell count of 8.1, sodium of 127, creatinine of 1.03 (baseline 0.7-9.8), lactic acid of 3.1 and lipase of 304. CTA chest/abdomen/pelvis revealed a 17 cm air-fluid mediastinal collection between the heart and descending thoracic aorta, concerning for distal esophageal perforation. He was evaluated by thoracic surgery and underwent VATS mediastinal washout, EGD with esophageal stent placement, and bronchoscopy. He required prolonged ICU stay due to septic shock, pressor support, and management of multiple drains. Empiric antibiotics included vancomycin, cefepime, metronidazole, and micafungin. Surgical cultures eventually grew Enterobacter, Lactobacillus, gamma-hemolytic Streptococcus, viridans group Streptococcus, and Candida intermedia. Antibiotics were narrowed to ampicillin-sulbactam, levofloxacin, and micafungin. He later developed Kluyveromyces marxianus infection at the chest wall incision, prompting a switch from micafungin to fluconazole. Patient's clinical condition steadily improved, and an Endo-VAC replaced the stent 10 days later. He was discharged home three days later. Discussion Mediastinal abscess should be suspected in patients with unexplained chest pain or sepsis, especially with a history suggestive of vomiting, potentially suggesting esophageal perforation. High clinical suspicion and timely imaging lead to early recognition and management. Multidisciplinary approach is essential to reduce morbidity and mortality associated with this life-threatening condition. This abstract is funded by: None
Felipe et al. (Fri,) studied this question.