Fever, sore throat and chest pain in a 9 year old.

1. Fever, sore throat and chest pain in a 9 year old. Angie Hartsell, MD David Fitzgerald, MD Wednesday ID Case Conference March 12, 2008

2. HPI • Pt is a 9 yo previously healthy male who presented to the emergency department with a 1 week history of cough, rhinorrhea, chest pain, fever and sore throat. • He had diarrhea and vomiting for the initial 2-3 days of his illness, but this resolved. • He describes the chest pain as sharp and located at the sternal notch. His chest pain and fever have gotten worse as his other symptoms are improving. • He describes waking up sweaty for the past 5 days. • He denies difficulty breathing, wheezing, or stridor. • He does admit to a change in his voice. He denies dysphagia or odynophagia. He admits to “spitting a lot” over the past 2 days. • He has had decreased appetite and energy, but is drinking normally. • Admits to 2 lb weight loss over the last 4 months. His mom and two of his aunts are sick with upper respiratory infections.

3. HPI • Medications: steroid cream for eczema • Allergies: NKDA • PMH: Eczema. No prior hospitalizations or surgeries. • FMH: Maternal uncle with asthma, otherwise negative. • SHX: Lives with his mom, sister, and a cousin. No smokers. No pets. He’s in the 4th grade.

4. Physical Exam • Temp 103.1, HR 128, BP 113/72, RR 18, O2 sat 96 % on RA. • General: breathing comfortably and in no apparent distress. He was non toxic appearing. • HEENT: NC/AT, PERRL, sclera and conjunctivae clear. Small amount of clear drainage from his nares. His lips were dry but not cracked. His orophaynx was moist with mild erythema but no exudates. His TMs were normal bilaterally. • Neck: soft, supple, without lymphadenopathy. • CV: RRR, no m/r/g. • Chest: His lungs were clear bilaterally with good air movement and no wheezes, rales, rhonchi.

5. Physical Exam • Abd: Bowel sounds were present. His abdomen was soft, non tender, non distended, without hepatosplenomegaly. • GU: Genital exam showed normal tanner I male with testes descended bilaterally. He had dry skin flaking off of his testicles, but not involving the urethra. He had circular desquamation surrounding the anus, so that the skin was pink in a 4-5 cm diameter. • Skin: His palms were desquamated in thick sheets and he was actively picking at the skin. The skin on his feet were intact with no signs of desquamation. • EXT: He had normal pulses and capillary refill time was less than 2 seconds. • Neuro: Grossly intact. Non-focal.

6. Labs • CBC • 30.7>11.1/32.1<441 87% neutrophils, 9% lymphs • Na 129, K 3.1, Cl 92, CO2 23, BUN 13, Cr 0.85, Ca 8.6, Tprot 7.4, Alb 2.2, AST 52

9. Discussion

10. Follow-Up • Patient was sent to WFUBMC where he received antibiotics and broke out in a scarlatinaform rash • He received IV Unasyn and surgical drainage by dorsal thoracotomy. • Cultures sent grew Group A Strep. • He was discharged after 5 days on 14 additional days of Augmentin.

11. Mediastinitis • Anatomic

12. Anatomic considerations • The region between within the thorax between the pleural sacs extending from diaphragm to superior aperture of thorax • Three major routes of spread of infection from head and neck to mediastinum include • 1. pretracheal space • Long fascial planes of posterior neck • Viscerovascular or lateral pharyngeal space

13. Causes of acute mediastinitis • Mediastinitis due to infections of the head and neck and contiguous structures • Esophageal perforation • Head and Neck infections – odontogenic, Ludwigs angina, pharyngitis, tonsillitis, parotitis, epiglottis, lemierre’s syndrome • Infections originating at other sites – Pneumonia, empyema, pancreatitis, cellulitis of chest wall, lymph node necrosis and hemorrhage (anthrax) or casseous necrosis (TB) • CT surgery • Histoplasma can cause a sclerosing mediastinitis

14. Microbiology of mediastinitis • Head and neck – largely polymicrobial, often synergistic infection made up of a number of oral anaerobes and GNR • Anaerobic – peptostrep, actinomycese, bacteroides, fusobacterium, Prevotella, Porphyromonas • Aerobic Strep, Staph, diphtheroids, GNR, Candida • CT surgery – largely GPC (less GNR) • Staph aureus, Epi, Enterococcus, Strep, many others

15. Microbiology of mediastinitis • CT surgery – largely GPC (less GNR) • Staph aureus, Epi, Enterococcus, Strep

16. Clinical presentation • Usually will have obvious primary infections with pain , fever and swelling at primary site • Also chest pain, resp distress and odynophagina • Hamman’s sign – a crunching rasping sound heard over the precordium with heartbeat • Crepitus in supraclavicular region

17. Treatment • Prompt surgical drainage and appropriate antibiotics directed against mixed oropharyngeal infection

18. Complications of Tonsillitis • See Table I in: Bell, Z, Menezes AA, Primrose, WJ, McGuigan, JA. Mediastinits: a life threatening complication of acute tonsillitis. J Laryngol Otol. 2005 Sep; 119 (9), 743-5.

19. Complications of descending necrotizing mediastinitis • See Table II in: Bell, Z, Menezes AA, Primrose, WJ, McGuigan, JA. Mediastinits: a life threatening complication of acute tonsillitis. J Laryngol Otol. 2005 Sep; 119 (9), 743-5.

20. Search PubMed • Acute Mediastinitis • Case Reports • Review • Differential Diagnosis • Therapy Note: In order to see PubMed results, use ViewSlide Show, or hit F5