As a third year resident, in my “unaccredited registrar” year (before I was accepted into surgical training), I worked as a Cardiothoracic registrar. It was a lucky break, as I never asked to do it, and I was meant to do six months of nights and holiday covers instead. But it was a bit intimidating to be first on call for Cardiothoracics, a speciality I had previously never worked. Our roster was a week on call, once every four weeks. It was pretty gutting.
One night I got a call from the ED staff saying they had a sick young male with some sort of chest infection. It was a weird call, but as a really junior registrar, with no experience, I was not going to turn anything down without passing it by my consultant.
This 20-something guy had been sick with an URTI for a few days. He started to get headaches and feel unwell, and he finally went to his doctor and was diagnosed with Quinsy or peritonsillar abscess. It’s not unheard of, but it is an unusual thing to call a cardiothoracic Reg for. So he has his throat lanced and he has appropriate antibiotics, but he looks sicker than that. Luckily, the ED docs decide to CT his neck, and find gas bubbles. So the radiologist extends the scan and finds gas bubbles in his mediastinum (the bit of the chest between the lungs that encloses the heart, and major arteries, oesophagus, nerves and all good things.).
In theatre that evening, the young man had a thoracotomy to drain pockets of stinky pus from all around his heart. Black-brown strings of pus, lying over pulsing things – B-grade-movie-worthy. That was insufficient, so he also got a median sternotomy. He had four wide gauge chest tubes that continued to clog up in ICU for the next week, leading us to institute continual pleural lavage for a few nights. And he went back to theatre so many times, we lost count. Eventually, he got his wounds closed. He even left hospital, about 20kg lighter.
He was a really nice guy, and really happy to do whatever it took. Not surprising, really. I would have been, too. Because he was just young when it happened, I can’t help thinking that his life is now defined by that completely random earth-shattering event. As his death would have been, I suppose.
Not to be obtuse here, but what grew out of the cultures? Did you figure out how he got the infection? Very interesting
Not obtuse, as it was an interesting case. It happened 5 years ago, so details are not crystal clear in my head. The bug was a standard throat bug – Strep I think. Very sensitive to antibiotics, so the difficulty was clearing the pus and debris, not getting adequate antimicrobial coverage.
From memory, he never even got MRSA superinfection.
We thought the entrance point was his throat and somehow, through really bad luck, the infection entered his neck and tracked into his mediastinum. For some reason, he only got inflammation in his neck and not much pus. We drained his neck from below (and the absess was lanced into his pharynx), and that was sufficient.
He was not diabetic, or immunocompromized. He was fit and thin, and had no other medical problems. Zebra indeed.
I’ve seen a few pneumomediastinum + mediastinitis complicating neck space infections – only on CT scans, of course! Glad to know your patient got through it.
Wow. Thank goodness he didn’t get MRSA…
I still don’t get why he didn’t, but once he had all his lumens open, it was just going to be colonisation anyway. He was a lucky guy, but I guess he is probably still reminded of it, but huge scars, aches and pains. And he will probably never run a marathon.