Descending necrotizing mediastinitis: a case report of a rare and lethal infection

Descending necrotizing mediastinitis (DNM) is a rare but life-threatening infection that spreads from cervical or oropharyngeal regions into the mediastinum via fascial planes. Early diagnosis and prompt surgical intervention are essential to reduce its high mortality. We report a case of a 22-year-old male presenting with chest pain and dyspnea. He was diagnosed with DNM of odontogenic origin. Broad-spectrum antibiotics were initially ineffective. CT imaging confirmed mediastinitis with multiple abscesses. He underwent aggressive surgical intervention via right posterolateral thoracotomy. Per-operatively, a thick slough was noted over the lungs, diaphragm, and pericardium. The patient was extubated on postoperative day zero and discharged on the sixth day without complications. This case was unusual due to the patient’s young age, bilateral thoracic involvement managed via unilateral thoracotomy, and negative culture results despite extensive infection, posing a therapeutic challenge. It highlights that even healthy young individuals can develop DNM from dental infections. Early imaging, prompt drainage, and aggressive surgical management are critical to improve outcomes, even in extensive bilateral disease.