Descending mediastinitis mimicking a pharyngo-laryngeal neoplasia

Valverde-Jorge, R.; Fernández-Tercero, I.; Jiménez-Jiménez, M.; Jauregui-García, M.; Genollá-Subirats, J.; Rodeño-Ortiz de Zárate, E.

doi:10.1016/j.remnie.2022.09.009

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A) Imágenes de proyección de máxima intensidad (MIP) anterior y lateral izquierda: absceso hipermetabólico parafaríngeo derecho complicado con colecciones caudales en relación con mediastinitis descendente y empiema pleural izquierdo. B) Corte coronal en imágenes de fusión PET/TC en el que se observa una masa de partes blandas hipermetabólica (SUV máx: 7,6) submucosa parafaríngea derecha que impronta sobre la vía aérea y colapsa el seno piriforme en relación con absceso. C) Corte axial de fusión con colección hipermetabólica (SUV máx.: 8,1) que invade el espacio visceral y contacta con el borde anterior de glándula y cartílago tiroides, sobrepasando la línea media. D) Corte sagital de fusión que evidencia una extensa colección mediastínica restroesofágica-prevertebral descendente con realce periférico hipermetabólico sin afectar a los cuerpos vertebrales. 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She started adjuvant chemotherapy treatment presenting complete response and after two years relapsed with pathological mediastinal, mesenteric and pelvic lymphadenopathies, for which she started a new chemotherapy treatment with good response. On the PET/CT scan performed to characterize a pulmonary nodule seen in a follow-up CT scan, the only finding was a lesion with ring-shaped hypermetabolism and trabeculation of the perilesional fat suggestive of epiploic appendagitis. PET/CT study acquired 60 min after the intravenous administration of 222 MBq of 18FFDG. (a and b) Maximum intensity projection (MIP) coronal, supravesical hypermetabolic lesion is observed (blue arrow). (C–e) axial and sagittal PET/CT showing a 2.3 cm ovoid fatty lesion adjacent to the sigma with ring-shaped hypermetabolism (SUVmax 7.2) and trabeculation of the perilesional fat. f) Axial plane of control CT carried out two months later showing no evidence of the lesion that had responded to anti-inflammatory treatment." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P. Guardia Jimena, M.V. Guiote Moreno, A.M. Santos Bueno, J.A. Vallejo Casas" "autores" => array:4 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Guardia Jimena" ] 1 => array:2 [ "nombre" => "M.V." "apellidos" => "Guiote Moreno" ] 2 => array:2 [ "nombre" => "A.M." "apellidos" => "Santos Bueno" ] 3 => array:2 [ "nombre" => "J.A." 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Valverde-Jorge, I. Fernández-Tercero, M. Jiménez-Jiménez, M. Jauregui-García, J. Genollá-Subirats, E. Rodeño-Ortiz de Zárate" "autores" => array:6 [ 0 => array:4 [ "nombre" => "R." "apellidos" => "Valverde-Jorge" "email" => array:1 [ 0 => "rvaljor@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "I." "apellidos" => "Fernández-Tercero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "M." "apellidos" => "Jiménez-Jiménez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "M." "apellidos" => "Jauregui-García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "J." 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"apellidos" => "Rodeño-Ortiz de Zárate" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Nuclear, Hospital Universitario Cruces, Baracaldo (Vizcaya), Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Otorrinolaringología, Hospital Universitario Cruces, Baracaldo (Vizcaya), Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Radiodiagnóstico, Hospital Universitario Galdakao-Usansolo, Galdácano (Vizcaya), Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Mediastinitis descendente que simula una neoplasia faringo-laríngea" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1790 "Ancho" => 2925 "Tamanyo" => 294129 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "[18F]FDG PET/CT study: A) Anterior and left lateral maximum intensity projection (MIP) images: right parapharyngeal hypermetabolic abscess complicated with caudal collections in relation to descending mediastinitis and left pleural empyema. B) Coronal PET/CT fusion images showing a right parapharyngeal submucosa hypermetabolic soft tissue mass (SUVmax: 7.6) obliterating the airway and collapsing the piriform sinus in relation to abscess. C) Fusion image in axial section showing hypermetabolic collection (SUVmax: 8.1) invading the visceral space and contacting the anterior border of the thyroid gland and cartilage, surpassing the midline. D) Sagittal fusion section showing an extensive descending restroesophageal-prevertebral mediastinal collection with hypermetabolic peripheral enhancement without affecting the vertebral bodies. E) Axial section showing left pleural effusion and hyperenhancement of the pleural layers in relation to empyema." ] ] ] "textoCompleto" => "A 55-year-old man presented to the emergency department for dysphagia and weight loss for a week, without fever, signs of oropharyngeal infection or other symptoms.Physical examination revealed a right pharyngeal submucous mass descending to ventricular bands, right vocal cord paresis and a stony adenopathic conglomerate at levels III-IV. The chest X-ray showed alveolar consolidation at the base of the left lower lobe suggestive of infection. Laboratory tests showed elevated CRP with leukocytosis, attributed to the pneumonic process. Suspicion of probable pharyngeal neoplasia with lymph node involvement led to patient admission for pneumonia management and to complete the extension study, initiating antibiotic treatment.A biopsy of the pharyngeal mass and PET/CT with [18F]FDG and iodinated contrast for staging was performed, which showed a hypermetabolic mass in the right pharyngolaryngeal submucosa, with an abscessified appearance and obliteration of the pyriform sinus (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Extension from the retropharyngeal space to the prevertebral-retroesophageal space was also observed, showing a continuous pattern of hypermetabolic collections ending in left pleural empyema. No uptake suggestive of vertebral osteomyelitis was identified.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>In light of the PET/CT findings, an emergency cervicotomy and thoracotomy to drain the abscesses and empiemas was performed. The patient remained stable and with good radiological evolution during the resto of the hospitalization, and was discharged after 14 days. The histopathological examination was negative for malignancy, showing connective tissue and predominance of acute inflammatory cellularity.Non-traumatic descending mediastinitis is an infection affecting mediastinal connective tissue, rare in immunocompetent adults, but potentially life-threatening (30–50% linked to delayed diagnosis and late initiation of treatment). It occurs as a complication of a cervical oropharyngeal or dental infection that spreads through the cervical spaces to the mediastinum, favored by intrathoracic negative pressure and gravity. The clinical context is crucial, raising the differential diagnosis with other hypermetabolic lesions such as tuberculosis, lymphoma, mediastinal desmoid tumor, mediastinal metastases, atypical sarcoidosis or Castleman's disease<a class="elsevierStyleCrossRef" href="#bib0005">1</a>.In our case, the PET/CT findings allowed the diagnosis leading to an early and aggressive approach, thus avoiding the associated high mortality." "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-04-09" "fechaAceptado" => "2022-07-28" "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1790 "Ancho" => 2925 "Tamanyo" => 294129 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "[18F]FDG PET/CT study: A) Anterior and left lateral maximum intensity projection (MIP) images: right parapharyngeal hypermetabolic abscess complicated with caudal collections in relation to descending mediastinitis and left pleural empyema. B) Coronal PET/CT fusion images showing a right parapharyngeal submucosa hypermetabolic soft tissue mass (SUVmax: 7.6) obliterating the airway and collapsing the piriform sinus in relation to abscess. C) Fusion image in axial section showing hypermetabolic collection (SUVmax: 8.1) invading the visceral space and contacting the anterior border of the thyroid gland and cartilage, surpassing the midline. D) Sagittal fusion section showing an extensive descending restroesophageal-prevertebral mediastinal collection with hypermetabolic peripheral enhancement without affecting the vertebral bodies. E) Axial section showing left pleural effusion and hyperenhancement of the pleural layers in relation to empyema." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:1 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "18F-fluorodeoxyglucose positron emission tomography/computed tomography findings in descending necrotizing mediastinitis and cervical vertebral osteomyelitis in a cancer patient" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Y. Young" 1 => "Y. Min Young" 2 => "L. Ki Hyeong" 3 => "K. Sung-Soo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/MD.0000000000021353" "Revista" => array:2 [ "tituloSerie" => "Clin Case Rep" "fecha" => "2020" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/22538089/0000004200000003/v2_202401190458/S2253808922000982/v2_202401190458/en/main.assets" "Apartado" => array:4 [ "identificador" => "47121" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Interesting image" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/22538089/0000004200000003/v2_202401190458/S2253808922000982/v2_202401190458/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2253808922000982?idApp=UINPBA00004N"]

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The Revista Española de Medicina Nuclear e Imagen Molecular (Spanish Journal of Nuclear Medicine and Molecular Imaging), was founded in 1982, and is the official journal of the Spanish Society of Nuclear Medicine and Molecular Imaging, which has more than 700 members. The Journal, which publishes 6 regular issues per year, has the promotion of research and continuing education in all fields of Nuclear Medicine as its main aim. For this, its principal sections are Originals, Clinical Notes, Images of Interest, and Special Collaboration articles. The works may be submitted in Spanish or English and are subjected to a peer review process. In 2009, it became the leading Spanish journal in the field of Medical Imaging on having an Impact Factor , awarded by the Journal Citation Reports.

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