Background: Descending Necrotising Mediastinitis (DNM) is an acute, life-threatening disease caused by infections originating in the head and neck area. Antibiotherapy and surgical debridement of the affected tissue are the cornerstones of treatment [1]

Case presentation: We admitted a 38-year old male to our ICU with clinical manifestations of severe sepsis. His condition had worsened in the previous two weeks following an unsuccessful antibiotic therapy for lacunar angina, complicated by retropharyngeal abscesses. CT and intraoperative observations identified abscesses in the anterior and middle mediastinum region and the distal part of the neck, directly
on the border with the left lobe of the thyroid gland. We confirmed Streptococcus alfa haemolyticus and Clostridium species positive cultures. PCT 20.5 μg/L, CRP 325.3 mg/L, WBC 19.8*103 cells/μL, Lactate 6,3 mmol/L, SVR < 500 dynes/sec/cm5 and the SAPS II score of 63 pointed to a case of severe sepsis with a poor prognosis.
The treatment consisted of an aggressive antibiotic regimen, transthoracic and mediastinal surgical evacuation of the abscess, vacuum sealing drainage with a pleural chest tube, continuous venovenous hemodiafiltration using cytokine-adsorbing hemofilters and intermittent Ozone therapy. We discharged the patient after 39 days with only mild dysphonia; he was fully recovered at day 92.

Discussion: DNM is a rapidly progressing life-threatening disease. Mediastinal infection can induce lethal septicaemia if not diagnosed and managed appropriately. Each case requires a personalised treatment modality [2].
In agreement with the European Association for Cardio-Thoracic Surgery recommendations [1], we initiated an aggressive antibiotic treatment. We succeeded with a targeted mediastinal surgical debridement of necrotic tissue, pleural and pericardial drainage and support of the vital organs. As adjuvant therapy, we
applied CVVHDF-CAH and Ozone therapy [3].
Our approach successfully treated the DNM-induced anaerobic septicemia and allowed a full recovery.

Learning points: Effective management of DNM-induced anaerobic septic shock requires a multidisciplinary therapy based on the timely administration of antibiotics, skilled surgical intervention and the use of adjuvant treatment modalities to support renal, pulmonary and hemodynamic functioning.

References: 
1 Abu-Omar Y. et al., Eur J Cardiothorac Surg 2017. 
2 Palma DM et al., Infection 2016.
3 Delgado-Roche L Eur. J. Pharmacology 2017.

02 / A Successful Multidisciplinary Intensive Care Approach of Anaerobic Septic Shock caused by Descending Necrotising Mediastinitis