MDCT findings of polymicrobial descending necrotizing mediastinitis

1A 43-year-old Caucasian male with an uneventful medical history presented to ER complaining of sore throat and fever of 38.3°C. Clinical examination revealed unilateral right sided tonsillitis. Over the next 4 days, he developed malaise, shortness of breath, right-sided neck swell ing and chest pain and he was admitted. The patient was systematically unwell with clinical manifestations of persistent neck swelling and pain radiating to the right shoulder, fever, slight discoloration of overlying skin, subcutaneous crepitation, mild trismus, odynophagia and decreased oral intake, in the setting of a peritonsillar abscess. Within a few hours after hospitalization, the patient presented upper airway obstruction due to massive edema, resulting in acute respiratory insufficiency that necessitated tracheal intubation and transfer to the ICU, while planning for surgical intervention. MDCT scan of the cervical and thoracic region (Fig. A,B,C) showed a parapharyngeal abcess descending into the mediastinum, spreading towards the diaphragm, with bilateral pleural effusions, along with diffuse necrotizing fasciitis, collection of gas in mediastinal compartments and soft tissue infiltration with loss of normal fat planes. The patient underwent combined extensive neck and thorax drainage in conjunction with limited surgical debridement consisting of cervicotomy. Swabs identified a polymicrobial infection with predominant species of Streptococcus pyogenes, anaerobic Peptostreptococci and Streptococcus viridans. The empirical antibiotic regimen included piperacillin – tazobactam and