A 77-year-old man presented to a dermatology clinic with chief complaints of pain and swelling in the bilateral dorsum of his feet for 1 week. His past history included alcoholic liver disease. He was diagnosed with cellulitis of the bilateral feet and underwent incisional drainage at a municipal hospital. He also had a bulge in the anterior chest wall, where he had been hit forcefully 2 weeks previously. His whole-body computed tomography (CT) scan revealed an extensive abscess that had destroyed sternal body and continued from the left anterior chest to the right anterior mediastinum (Fig. 1). Therefore, he was promptly transferred to our department for the management of the thoracic lesion. On arrival, he was conscious, and his circulatory and respiratory dynamics were barely maintained with supplemental fluids and oxygenation at 2 L/min. Renal function was impaired with a creatinine level of 3.1 mg/dL. His anterior chest showed a 5-cm-diameter bulge with redness. Both the patient’s feet had necrotic fascia, suggesting necrotizing fasciitis rather than cellulitis. His whole-body CT confirmed not only a continuous abscess in the thorax, but also a left sciatic rectus fossa abscess in the pelvis (Fig. 1). Trans-thoracic echocardiography revealed no evidence of infective endocarditis. The diagnosis was multiple deep organ abscesses, including anterior chest wall abscess, anterior mediastinal abscess, sternal osteomyelitis, sciatic rectus fossa abscess, and necrotizing fasciitis of both feet. His APACHE II score was calculated to be 26, with a high predictive in-hospital mortality rate.
Given that his general condition was unfavorable, and the right anterior mediastinum abscess was accessible, percutaneous drainage under local anesthesia was first performed in the emergency room via the right second intercostal space. Furthermore, small incisional drainage was performed for the left anterior chest wall abscess, and the necrotic pectoral muscles were debrided cautiously not to cause external pneumothorax via the abscess. After admission to the intensive care unit, vancomycin administration was initiated, which was subsequently switched to cefazolin when methicillin susceptible S. aureus was detected in blood and drained abscess culture tests. On the following day, while the mediastinal abscess shrunk, the right pleural effusion increased rapidly, likely due to mediastinal pleural injury during the first anterior mediastinal drainage (Fig. 2). Right pleural drainage showed pyothorax. The pleural effusion became more purulent rapidly over time after drainage. On the 3rd day of hospitalization, additional debridement of the anterior chest wall abscess and necrotizing fasciitis in both feet, and thoracoscopic pleural curettage were performed under general anesthesia as the systemic inflammation was not sufficiently improved by the previous drainage. The patient was positioned supine with a pillow under his back on the right side, and debridement of the anterior chest was performed, followed by concurrent thoracoscopic pleural curettage by thoracic surgeons and debridement of the lower extremities by plastic surgeons. Thoracoscopic pleural curettage was performed to control rapidly progressive pleural infection. The necrotic right second toe and left fifth toe were amputated. Although the sternal body was infected and extensively destroyed by the abscess, the sternum was left intact to prevent postoperative respiratory failure caused by sternal defects.
The inflammatory response improved, and his general condition recovered through intensive care, long-term cefazolin administration, aggressive rehabilitation, and appropriate nutritional management. However, the anterior chest abscess with sternum destruction was still infectious, and the left sciatic-rectal fossa abscess remained unresolved. To control the persistent infection, debridement of anterior chest wall, including the sternum, and sciatic-rectal fossa abscess incisional drainage were performed on the 24th day. The caudal half of the sternal body was resected, leaving the costal cartilage attachments in place (Fig. 3). Anterior chest wall incision was left open for postoperative daily washing. The patient’s general condition further improved without developing respiratory failure. Cefazolin was continued for 11 weeks. The patient was transferred to the general ward on the 43rd day. A latissimus dorsi myocutaneous flap was used to fill the sternal defect for wound closure and infection control 40 days after the second surgery when his general condition was further recovered (Fig. 3). The patient was finally discharged home, with anterior chest wall wound being closed, after 5 months of hospitalization.
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