A Case Report of Iatrogenic Esophageal Perforation: Complication of Orogastric Tube Placement

Introduction: Orogastric tube insertion is a routine procedure in medical care. However, misplacement of the tube can cause a variety of complications, which can be life threatening in some instances. Case Description/Methods: 71-year-old male presented with dyspnea, fever, chills, cough, and myalgia for 2 weeks. He had tachycardia, tachypnea, and was hypoxic to 66% in room air. He was found to have acute hypoxic respiratory failure secondary to COVID-19 Pneumonia and was admitted to ICU. But, he continued to be hypoxic and was started on BiPAP. He eventually became altered, and was intubated. Post intubation orogastric tube (OGT) placement was unsuccessful on the first attempt due to resistance. On the second attempt, the nurse was able to advance partially (Figure). But, a chest XR showed OGT in the mediastinum, and OGT was removed. CT of neck and chest revealed pneumomediastinum with possible mid-thoracic esophageal perforation. The patient was started on broad-spectrum antibiotics and thoracic surgery was consulted. Given his mechanical ventilation requirement, surgery deemed him unfit to tolerate thoracotomy and the endoscopic procedure was not available in the hospital. So, recommendation was to manage conservatively. His hospital course was complicated by hypotension requiring vasopressors and metabolic acidosis in setting of acute renal failure requiring CRRT. Code status was changed by the family to Do Not Resuscitate due to his deteriorating condition. Eventually, he had a PEA arrest and was expired. Discussion(s): OGT intubation is performed at hospitals for feeding, medication administration or gastric decompression. Although it is considered a safe procedure, complications can arise due to OGT misplacement or trauma caused by the OGT itself or the intubation process. OGT misplacement is typically endotracheal or intracranial. Misplacement within the upper GI lumen is usually detected by a kink in the oropharynx or esophagus. The subsequent complications are identified by the structure that is perforated (e.g., mediastinitis or pneumothorax). Regardless of whether counteraction is perceived, the physician must be careful not to apply excessive force. The location of the OGT tip should be determined by a chest radiograph;visualization of the tip below the diaphragm verifies appropriate placement. Complications of OGT insertion are uncommon;however, the consequences are potentially serious, and the anatomy of the upper GI tract should be understood by all who are involved in the care.

Tonsillar origin of deep neck infection as a negative prognostic factor for developing complications.

<b>Aim:</b> The aim of this study was to compare the odontogenic and tonsillar origins of deep neck infection (DNI) as a negative prognostic factor for developing complications. </br></br> <b>Methods:</b> This was a retrospective study of 544 patients with tonsillar and odontogenic origins of DNI treated between 2006 and 2015 at 6 ENT Departments and Departments of Oral and Maxillofacial Surgery. Complications from DNI (descending mediastinitis, sepsis, thrombosis of the internal jugular vein, pneumonia, and pleuritis) were evaluated in both groups and compared. Associated comorbidities (cardiovascular involvement, hepatopathy, diabetes mellitus respiratory involvement, gastroduodenal involvement) were reviewed. </br></br> <b>Results:</b> Five hundred and forty-four patients were analyzed; 350/544 males (64.3%) and 19/544 females (35.7%). There were 505/544 cases (92.8%) with an odontogenic origin and 39/544 cases (7.2%) with a tonsillar origin of DNI. Complications occurred more frequently in the group with tonsillar origin of DNI (P < 0.001). There was no difference in diabetes mellitus between the two groups. </br></br> <b>Conclusions:</b> Currently, the tonsillar origin of DNI occurs much less frequently; nevertheless, it carries a much higher risk of developing complications than cases with an odontogenic origin. We recommend that these potentially high-risk patients with a tonsillar origin of deep neck infections should be more closely monitored.

Idiopathic fibrosing mediastinitis with esophageal varices: A case report.

Fibrosing mediastinitis (FM) is a rare cause of lung fibrosis with multiple etiologies ranging from infectious to autoimmune to idiopathic. Common causes of FM include histoplasmosis and a relatively new cause of IgG4-related disease. We present a 55-year-old male with symptoms of esophageal varices, intractable hiccups, and progressive difficulty in breathing. A chest X-ray showed right lung fibrosis with pleural effusion and loss of lung volume, which was originally thought to be the sequelae of SARS-CoV-2 or metastasis, but computed tomography of the chest revealed FM. His variceal bleeding was controlled, and he was discharged home. However, treatment for FM was not pursued because the cause was not identified. Using corticosteroids may not cease the progression of the disease, and surgical options are available when symptoms persist. Idiopathic FM requires laboratory and radiological findings to exclude relevant differential diagnoses.

HYPOTENSION WITH ST ELEVATIONS.NOT A STEMI OR EVEN THE HEART

CASE: Mr. S is a 60 yo man with DM, HTN and HLD who presents to the urgent care (UC) clinic complaining of sore throat and phlegm in the throat. He is noted to have normal vital signs except for a BP of 75/47. Exam showed slight erythema of the oropharynx, normal cardiac and pulmonary exams. Initial treatment of fluid resuscitation is started for his presumed sepsis, thought secondary to presumed COVID-19 as this occurred during the Omicron surge. An EKG was performed showing anteriolateral ST elevations. The patient was transported emergently to the hospital. An immediate cardiac catheterization was performed which showed mild coronary artery disease, but no obstruction. At this time, COVID-19 PCR test returns negative. The patient is transfered to the MICU for further evaluation and treatment for hypotension/septic shock. At this time, a chest x-ray demonstrated subcutaneous gas in the soft tissues of the neck. CT imaging showed subcutaneous gas extending from the neck to the mediastinum. Patient was taken to the operating room and found to have significant pus in the neck and mediastinum. He was diagnosed with necrotizing mediastinitis requiring multiple surgical wash-outs and prolonged SICU stay. The source was a suspected dental extraction. His ST elevations were presumed to be secondary to a pericarditis effect from the mediasinitis. IMPACT/DISCUSSION: Overall, this case presents necrotizing mediastinitis which is a very unusual and rare presentation, however, it is a surgical emergency so internists need to be aware of this disease and its presentation. Additionally, this case identifies four important points. The first is to make a broad differential, specifically for hypotension. In the setting of a sore throat during the Omicron surge, it was easy to assume this was COVID-19 but thinking of other etiologies led to the EKG being performed. The second is the importance of the physical exam. After the CXR was seen, the patient was examined and noted to have subcutaneous gas which could have been noted at the initial UC visit but that piece of the exam was not performed as the focus was on the hypotension. Third, there is a differential for etiologies of ST elevation on EKG which include STEMI, pericarditis, early repolarization, etc. that should be considered while preparing for treatment of STEMI. Lastly, taking a extensive history, to include dental work, is important as there may be systemic effects of these experiences/treatments. CONCLUSION: -Make a broad differential for atypical patient presentations and physical exam findings -Review EKGs carefully and make a differential for those findings -Necrotizing mediastinitis is a rare presentation but life threatening and needs immediate surgical attention.

A rare complication after anti-SARS-CoV-2 vaccination: septic arthritis of the sternoclavicular joint, mediastinitis and pulmonary embolism

Introduction: The systemic side-effects of anti-SARS CoV-2 vaccination are described for all types of vaccines. We describe a case of a likely adverse reaction to the Spikevax Moderna vaccine, manifested by septic arthritis of the left sternoclavicular joint, mediastinitis and pulmonary embolism. Case Report: 22-year- old female soldier developed symptoms of fever, chest and limb discomfort in her left upper arm around 10 days after receiving her first dose of Spikevax Moderna vaccine, necessitating hospitalization 14 days after. Septic arthritis of the left sternoclavicular joint, mediastinitis, deep vein thrombosis of the left upper limb, and pulmonary embolism were diagnosed. The blood culture result showed the development of Staphylococcus aureus. The patient was treated with antibiotic therapy and with anticoagulant therapy. There was a rapid improvement in clinical conditions, allowing the patient to be discharged 10 days after admission. Conclusions: The vaccination's causative role in the formation of the clinical picture is extremely likely in this case, but with a plausible not-specific pathogenetic mechanisms. There have been reports of septic arthritis following SARS CoV2 vaccination, especially of the shoulder joint, but the novelty of our finding stems from the fact that it would be the first case of septic arthritis after vaccination involving a sternoclavicular localization. This case emphasizes the importance of maintaining a high degree of attention when administering vaccines and keeping a close eye on the patient in the days after the vaccine.

[Treatment of postoperative anterior mediastinitis, sternal osteomyelitis in a patient with a novel coronavirus infection]. / Lechenie posleoperatsionnogo perednego mediastinita, osteomielita grudiny u patsientki s novoi koronavirusnoi infektsiei (COVID-19).

The incidence of mediastinitis after median sternotomy makes up 1-3%. This complication results prolonged hospital-stay, significant increase in treatment cost and high mortality (up to 75%). Severe COVID-19 pneumonia is often manifested by coughing, that impairs sternum stability after osteosynthesis. Moreover, concomitant leukopenia increases the risk of mediastinitis. Viral pneumonia and mediastinitis are complicated by respiratory failure and mutually potentiate the negative effect. Negative pressure wound therapy (NPWT) with combined antibiotic therapy ensures a favorable outcome even in patients with postoperative mediastinitis and osteomyelitis combined with viral pneumonia.