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Mediastinitis is defined as acute or chronic inflammation of the mediastinal structures and generally has a low incidence. Invasive
community acquired methicillin resistant Staphylococcus aureus (ca-MRSA) is a rare serious life threatening infection. The
common conditions are cardiac revascularization procedures or esophageal perforation or a descending necrotizing mediastinits
secondary to an odontogenic focus. We present a rare case of acute necrotizing mediastinitis in a healthy young girl about 1 week
after diagnosis of influenza. An 18 year old female from Brooklyn with a past medical history of Gastroesophageal reflux disease
and a recent diagnosis of influenza-A, 6 days back presented to the emergency room with fevers, weakness and chest pain for 4 days.
Examination was pertinent for lethargy, ill looking female with tachycardia, tachypenia and decreased breath sounds bilaterally,
subsequent work up revealed elevated white blood cell count, CRP and ESR. CXR revealed mediastinal widening with normal lung
parenchyma. A CT scan of chest revealed diffuse confluent mediastinal adenopathy as well as diffuse thickening surrounding the
esophagus with infiltration of surrounding mediastinal fat suggestive of diffuse esophagitis and mediastinitis. Patient was started
on broad spectrum antibiotics. The progressive symptoms and imaging findings led to thoracotomy that revealed infected thymic
tissue with surrounding induration and infection in the mediastinal and pretracheal space which was debrided. The bacterial cultures
from the tissue as well as pleural fluid grew methicillin resistant Staphylococcus aureus. Pathology from the tissue revealed acute
necrotizing fibrinopurulent inflammation and fibrinopurulent exudate. Patient was treated with Vancomycin and Piperacillin/
Tazobactam which was later targeted to MRSA patient was discharged home on IV Daptomycin and completed 5 weeks of therapy
which was subsequently changed to PO Doxycycline. An MRI performed at 7 weeks of therapy revealed significant improvement in
prior mediastinits with no residual fluid or stranding.
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