A Serious Idiopathic Mediastinal Abscess Associated with Streptococcal Toxic Shock Syndrome Successfully Rescued by Surgery and Intensive Care: A Case Report

A Serious Idiopathic Mediastinal Abscess Associated with Streptococcal Toxic Shock Syndrome Successfully Rescued by Surgery and Intensive Care: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report A Serious Idiopathic Mediastinal Abscess Associated with Streptococcal Toxic Shock Syndrome Successfully Rescued by Surgery and Intensive Care: A Case Report Yoshihito Iijima, Masahito Ishikawa, Shun Iwai, Nozomu Motono, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8646249/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 33 You are reading this latest preprint version Abstract Background: Mediastinal abscesses are relatively rare; however, they have a wide range of causes. We encountered a patient with an idiopathic mediastinal abscess associated with streptococcal toxic shock syndrome due to a Group A streptococcal infection. The patient was successfully treated with two-stage surgery. Case presentation: A 66-year-old woman was diagnosed with mediastinal abscess accompanied by septic shock. Infection control was difficult, and the patient underwent incision and drainage of a mediastinal abscess. Postoperatively, the patient was treated using a combination of disseminated intravascular coagulation (DIC) therapy and polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP). Although the shock and DIC resolved, the mediastinal abscess recurred, and a second surgery was required. Blood analysis and culture revealed an idiopathic mediastinal abscess complicated by streptococcal toxic shock syndrome (STSS). One year and six months after the final surgery, the patient has been followed as an outpatient without evidence of recurrence. Conclusions: Here, we report a serious idiopathic mediastinal abscess associated with STSS that was successfully rescued with surgery and intensive care using PMX-DHP. idiopathic mediastinal abscess surgery streptococcal toxic shock syndrome septic shock disseminated intravascular coagulation Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Background Mediastinal abscesses are rare. Occasional reports of mediastinal abscesses have described those caused by oral or cervical infections 1) , sternoclavicular joint inflammation 2) , esophageal perforation 3, 4) , thoracic surgery 5) , and bronchoscopy after endobronchial ultrasound-guided transbronchial needle aspiration 6) . Here, we report a case of an idiopathic mediastinal abscess that was accompanied by septic shock, disseminated intravascular coagulation (DIC), and liver dysfunction. The patient was diagnosed with streptococcal toxic shock syndrome (STSS) based on blood culture results revealing a Group A streptococcal infection. The patient survived as a result of two surgeries and a combination of antibiotics, DIC therapy, and polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP). Case presentation A 66-year-old woman with a history of proximal gastrectomy for gastric cancer and right mastectomy for breast cancer called an ambulance complaining of fever, fatigue, and fecal incontinence. She was diagnosed with shock following vital sign measurements revealing a blood pressure of 76/43 mmHg, temperature of 38.7 °C, pulse rate of 126 bpm, and oxygen saturation of 89%. Chest radiography revealed a widened superior mediastinum and atelectasis of the left lower lung field ( Figure 1 ). Blood and urine test results at the time of transport are shown in Table 1 . Severe inflammation with septic shock, liver dysfunction, renal dysfunction, and coagulation abnormalities were observed. Because shock was diagnosed, the patient underwent contrast-enhanced computed tomography (CT) of the chest, abdomen, and pelvis ( Figure 2 ). A low-density area was detected in the upper mediastinum, suggesting a mediastinal abscess. An otolaryngologist performed a laryngeal fiberoptic scan, which did not reveal pyorrhea or abscess formation in the laryngopharynx or alveola. No findings suggestive of cellulitis were observed on the body surface. The patient’s progress after admission is shown in Table 1 and Figure 3 . The patient was diagnosed with septic shock due to an idiopathic mediastinal abscess and was immediately admitted to the intensive care unit where therapy with continuous catecholamines and combination meropenem and clindamycin was initiated. Although blood pressure stabilized, blood tests performed the next morning revealed persistent inflammation, and a mediastinal incision and drainage procedure was performed. The Thoracic Surgery, Gastrointestinal Surgery, Emergency Medicine, and Anesthesiology departments discussed treatment; because the primary focus of the abscess was found on the left side of the esophagus, the left side was to be treated first. Furthermore, it was decided that the Gastrointestinal Surgery department would use upper gastrointestinal endoscopy to observe the esophageal lumen and gastroesophageal anastomosis during surgery. First surgery ( Figure 4 ) After establishing separate lung ventilation, the patient was placed in the right lateral position, and the left thoracic cavity was approached using three-port video-assisted thoracic surgery (VATS). Opaque white pleural fluid, measuring 500 mL, was rapidly aspirated. The entire pleura was noted to be thickened owing to inflammation as the mediastinal pleura was incised along the aortic arch. The left main pulmonary artery and left superior pulmonary vein were identified; however, no abscesses were found in the vicinity. Incisions were made dorsal to the subclavian artery and ascending aorta to allow for pus drainage. The thoracic cavity was thoroughly irrigated and drains were placed dorsal to the left lung apex, anterior mediastinum, and diaphragm. The patient was then placed in the left lateral position, and the right thoracic cavity was approached using the three-port VATS. Similar to the left side, 700 ml of opaque white pleural fluid was removed from the thoracic cavity. An abscess was located at the intersection of the azygos vein and the esophagus, and it was incised and drained. An incision was also made below the carina. During surgery, a gastroenterologist performed an upper gastrointestinal endoscopy, and ruled out esophageal perforation. After thorough irrigation of the right side, drains were placed in the abscess cavity behind the apex of the lung, anterior mediastinum, and diaphragm, and the surgery was completed. Postoperative course after the first surgery Postoperative blood analysis results led to a diagnosis of DIC. After consultation with the hematology department, thrombomodulin, antithrombin, and γ-globulin were initiated. Blood culture results suggested a gram-positive cocci infection, but the possibility of mixed infection could not be ruled out; therefore, PMX-DHP was performed for two days. On postoperative day (POD) 2, blood pressure stabilized, and catecholamines were discontinued. The patient was extubated and weaned from the ventilator on POD 3; however, sputum production was impaired, and a tracheotomy was performed on POD 6. Group A Streptococcus (GAS) was detected in blood cultures, and the patient was diagnosed with septic shock, DIC, and liver dysfunction, meeting the criteria for STSS. Subsequently, white blood cell count gradually increased, and a repeat chest contrast-enhanced CT scan was performed, revealing recurrence of the mediastinal abscess on the cranial and dorsal sides of the aortic arch and the dorsal side of the trachea and bronchi. CT-guided drainage of the abscess was performed on the dorsal side of the left upper mediastinum, followed by a second surgery on POD 12 ( Figure 5 ). Second surgery Separate lung ventilation was established. With the patient in the right lateral position, extensive pulmonary adhesions were observed inside the thoracic cavity using the port (drain insertion site) from the first surgery. Thus, a 15 cm thoracotomy was performed in the third intercostal space, and an approach to the left thoracic cavity was formed. After dissecting adhesions, the cranial and caudal sides of the aortic arch were thoroughly dissected by a cardiovascular surgeon to avoid aortic injuries. The left main bronchus, esophagus, and area inferior to the tracheal carina were thoroughly dissected and irrigated. Drains were placed on the cranial and caudal sides of the aorta, and inferior to the tracheal carina. An optical drain was placed on the lateral side of the latissimus dorsi muscle, and incisions were closed. Postoperative course All drains were removed by POD 23 after the first surgery. The mediastinal abscess did not recur, and the patient was discharged on POD 33. One year and six months have passed since the second surgery, and the patient is still receiving follow-up at the outpatient clinic without evidence of recurrence ( Figure 6 ). Discussion Mediastinal abscesses often occur as a complication of descending necrotizing mediastinitis (DNM) following oral or cervical infection and can progress to sepsis and become fatal 7) . Mediastinal abscesses often spread aggressively into the mediastinal connective tissues and cause severe illness with sepsis. Emergency surgical treatment, including a wide drainage field, is necessary to prevent critical deterioration. According to the 2023 annual report of the Japanese Association for Thoracic Surgery, 24,024 surgeries were performed for nonneoplastic diseases, of which 134 (0.6%) were for DNM, with a 30-day mortality rate of 4.5% 8) . Sugio et al. reported that the 30-day and 90-day postoperative mortality rates in 225 patients with DNM were 3.6% and 5.3%, respectively. Furthermore, the 3- and 5-year survival rates were 84.9% and 68.6%, respectively 7) . They classified infections that were limited to areas superior to the carina level as type I and those that spread to the lower mediastinum as type II. Type II infection was identified as an independent risk factor for 90-day mortality. This patient had no history of preceding infections, such as odontogenic, pharyngeal, cervical, or sternoclavicular joint inflammation. She had not experienced any episodes of fish bone aspiration that could have led to esophageal perforation. Preoperative CT tomography did not reveal any findings suggestive of perforation at the anastomotic site after the proximal gastrectomy. Intraoperative upper gastrointestinal endoscopy revealed no abnormalities. Therefore, an idiopathic mediastinal abscess was diagnosed. The abscess extended from the superior to the posterior mediastinum below the tracheal carina, corresponding to type II in the classification by Sugio et al. 7) . STSS is a very rare complication of GAS infection and is defined with the following clinical manifestations occurring within the first 48 h of hospitalization or, for a nosocomial case, within the first 48 h of illness 9, 10) : 1) hypotension defined by a systolic blood pressure ≤ 90 mmHg for adults or less than the fifth percentile by age for children aged < 16 years; 2) multi-organ involvement characterized by two or more of the following: a) renal impairment: creatinine ≥ 2 mg/dL for adults, greater than or equal to twice the upper limit of normal for age for children, or a greater than two-fold elevation over the baseline level for patients with pre-existing renal disease; b) coagulopathy, including platelets ≤ 100,000/mm 3 or DIC, defined by prolonged clotting times, low fibrinogen level, and the presence of fibrin degradation products; c) liver involvement, including alanine aminotransferase, aspartate aminotransferase, or total bilirubin levels greater than or equal to twice the upper limit of normal for the patient’s age, or in patients with pre-existing liver disease, more than two-fold higher than the baseline level; d) acute respiratory distress syndrome, defined by acute onset of diffuse pulmonary infiltrates and hypoxemia in the absence of cardiac failure, or evidence of pleural or peritoneal effusion with hypoalbuminemia; e) generalized erythematous macular rash that may desquamate; or f) soft tissue necrosis, including necrotizing fasciitis, myositis, and gangrene. This patient experienced septic shock upon emergency transport, and GAS was identified in the blood cultures. After admission, catecholamines were administered to stabilize vital signs, and emergency surgery was performed. Intensive treatment for DIC and sepsis was administered postoperatively. Because the patient was in septic shock at the time of admission and developed liver dysfunction and DIC within 48 hours of admission, we diagnosed the patient with a mediastinal abscess complicated by STSS. Although there is limited evidence regarding PMX-DHP in the treatment of STSS, occasional reports have suggested its usefulness 11, 12) . The patient's blood pressure increased promptly after use of PMX-DHP, and continuous catecholamine administration was terminated. Therefore, we believe the combination of PMX-DHP with sufficient antibiotic administration and intravenous gamma-globulin therapy contributed to saving the patient's life. Mediastinal abscesses often require emergency surgery, and a treatment strategy must be devised within a limited timeframe. In DNM, the average time from the onset of chest symptoms to mediastinal drainage has been reported to be 1.8 days, and delays in diagnosis and treatment have a direct impact on life prognosis 13) . There are some points to reflect on in this case. Initial preoperative evaluation suggested a left-sided abscess which found on the left side of the esophagus; however, unlike preoperative imaging results, the abscess was predominantly located in the right posterior mediastinum at the time of the first surgery. Because the left side surgery was performed first, the left mediastinal tissue was destroyed; thus, the subsequent right-sided surgery allowed pus to drip into the left side, possibly leading to the development of the left mediastinal abscess and empyema. As a result, it recurred with a left middle mediastinal abscess and empyema, and a second surgery was necessary to save the patient's life. However, this study suggests that the order of the left-right approaches may reduce the need for reoperation. Conclusion Mediastinal abscesses often spread aggressively into the mediastinal connective tissues, cause severe illness with sepsis, and often require emergency surgery. Treatment strategies must be devised within a limited timeframe. Here, we have reported a serious idiopathic mediastinal abscess associated with STSS that was successfully treated with surgery and intensive care using PMX-DHP. Abbreviations DIC disseminated intravascular coagulation STSS streptococcal toxic shock syndrome CT computed tomography VATS video-assisted thoracic surgery PMX-DHP polymyxin B-immobilized fiber column direct hemoperfusion POD postoperative day GAS Group A streptococcus DNM descending necrotizing mediastinitis Declarations Acknowledgments We would like to thank Editage (www.editage.jp) for the English language editing. Funding None. Authors’ contributions YI participated in the surgery, conceived, and conducted the study, and performed the literature search. MI and HU performed the surgeries. MI, SI, NM, and HU supervised the manuscript preparation and revision. All the authors have read and approved the final version of this manuscript. Availability of data and materials All data generated or analyzed during this study are included in this published article. Ethics approval and consent to participate This study did not require ethical approval from our institution. Informed consent for participation in this study was obtained from the patient. Consent for publication Written informed consent was obtained from the patient for the publication of this report and its accompanying images. Competing interests The authors declare that they have no competing interests. References Guo J, Lin L, Zhou H, Yang W, et al. Descending necrotizing mediastinitis caused by Streptococcus constellatus: A case report and review of the literature. Med (Baltim). 2023;102:e33458. https://doi.org/10.1097/MD.0000000000033458 Nakamoto K, Hagiya H, Hayashi R, et al. Mediastinal abscess induced by Group B Streptococcus. Intern Med. 2023;62:491–2. https://doi.org/10.2169/internalmedicine.9498-22 Fu T, Chen J, Xiong B, et al. The first case of esophageal mediastinal fistula after immunotherapy for non-small cell lung cancer: Case report and literature review. J Cardiothorac Surg. 2025;20:9. https://doi.org/10.1186/s13019-024-03207-7 Zhong S, Wu Z, Wang Z. Successful treatment of fishbone-induced esophageal perforation and mediastinal abscess: A Case report and literature review. Am J Case Rep. 2023;24:e942056. https://doi.org/10.12659/AJCR.942056 Cao J, Geng M, Huang X, et al. New improved incision-tubing approach for bronchoesophageal fistula with mediastinal abscess after esophagectomy: A case report. Front Surg. 2023;10:1100264. https://doi.org/10.3389/fsurg.2023.1100264 Ishimoto H, Yatera K, Uchimura K, et al. A serious mediastinum abscess induced by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA): A case report and review of the literature. Intern Med. 2015;54:2647–50. https://doi.org/10.2169/internalmedicine.54.4465 Sugio K, Okamoto T, Maniwa Y, et al. Descending necrotizing mediastinitis and the proposal of a new classification. JTCVS Open. 2021;8:633–47. https://doi.org/10.1016/j.xjon.2021.08.001 Committee for Scientific Affairs, The Japanese Association for Thoracic Surgery, Yoshimura N, Sato Y, Takeuchi H, et al. Thoracic and cardiovascular surgeries in Japan during 2023: Annual report by the Japanese Association for Thoracic Surgery. Gen Thorac Cardiovasc Surg. 2025;73:526–65. https://doi.org/10.1007/s11748-025-02128-z Case definitions for infectious conditions under public health surveillance (RR-10). Centers for Disease Control and Prevention MMWR Recomm Rep.;p. 1–55; 1997;46 Thacharodi A, Hassan S, Vithlani A, et al. The burden of group A Streptococcus (GAS) infections: The challenge continues in the twenty-first century. iScience. 2024;28:111677. https://doi.org/10.1016/j.isci.2024.111677 Iwashita K, Kobayashi A, Takada A, et al. Primary streptococcal peritonitis treated conservatively－a case report－. Nihon Rinsho Geka Gakkai Zasshi (J Jpn Surg Assoc). 2019;80:798–803. https://doi.org/10.3919/jjsa.80.798 (in Japanese with English abstract) Nakayama A, Sato N, Takai Y, et al. A case of peritonitis associated with streptococcal toxic shock syndrome after colorectal cancer surgery. J Jpn Abd Emerg Med. 2018;38:771–6. https://doi.org/10.11231/jaem.38.771 (in Japanese with English abstract) Mihos P, Potaris K, Gakidis I, et al. Management of descending necrotizing mediastinitis. J Oral Maxillofac Surg. 2004;62:966-72. https://doi:10.1016/j.joms.2003.08.039. Table Table 1 is available in the supplementary files section Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8646249","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":591503008,"identity":"1e0b0d61-6738-4ec1-83d0-0798627e49c2","order_by":0,"name":"Yoshihito Iijima","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAuklEQVRIiWNgGAWjYDAC+YcNBz5UwHg8ROlJPvhwxhnStKQlG3O2keSuhjNm0ozz7kTLNzA//MAgc4ewFoODPWbShdue5W44wGYswcDzjAgtzDxm0jO3Hc7dwMBgBvTLYSIc1gbUwjvncO78BvZvxGlhOMOWbMzbcDi34QAPkbYY3GAGBvIxoMMO8xRLJBDjF/kZjMCorAE6rL1944ePPUSEGAIwA3FizwFStIDBD9K1jIJRMApGwfAHAClEPOf9k7amAAAAAElFTkSuQmCC","orcid":"","institution":"Kanazawa Medical University","correspondingAuthor":true,"prefix":"","firstName":"Yoshihito","middleName":"","lastName":"Iijima","suffix":""},{"id":591503009,"identity":"ddbff21d-6eb6-4b40-afae-8d7bea988a3c","order_by":1,"name":"Masahito Ishikawa","email":"","orcid":"","institution":"Kanazawa Medical University","correspondingAuthor":false,"prefix":"","firstName":"Masahito","middleName":"","lastName":"Ishikawa","suffix":""},{"id":591503010,"identity":"70e58d70-6fec-4a16-81cb-7a8e8caf5a0c","order_by":2,"name":"Shun Iwai","email":"","orcid":"","institution":"Kanazawa Medical University","correspondingAuthor":false,"prefix":"","firstName":"Shun","middleName":"","lastName":"Iwai","suffix":""},{"id":591503011,"identity":"0dad1d80-d898-4dca-973c-2d857af4cdd6","order_by":3,"name":"Nozomu Motono","email":"","orcid":"","institution":"Kanazawa Medical University","correspondingAuthor":false,"prefix":"","firstName":"Nozomu","middleName":"","lastName":"Motono","suffix":""},{"id":591503012,"identity":"1458235a-c73a-4e9b-a935-82f8cab97ce2","order_by":4,"name":"Hidetaka Uramoto","email":"","orcid":"","institution":"Kanazawa Medical University","correspondingAuthor":false,"prefix":"","firstName":"Hidetaka","middleName":"","lastName":"Uramoto","suffix":""}],"badges":[],"createdAt":"2026-01-20 07:32:39","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8646249/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8646249/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102748965,"identity":"f34e35ed-b3e1-42b1-a16f-c0ffe62d53f3","added_by":"auto","created_at":"2026-02-16 09:11:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":581343,"visible":true,"origin":"","legend":"\u003cp\u003eChest X-ray findings at the time of emergency transport.\u003c/p\u003e\n\u003cp\u003eChest radiography revealing an enlarged upper mediastinum and atelectasis in the left lower lung field.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8646249/v1/614cddf3b56262fe8b8fa597.png"},{"id":102739648,"identity":"23194e68-aadf-4c61-9553-e790ca7acdfd","added_by":"auto","created_at":"2026-02-16 07:11:05","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1865508,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative findings.\u003c/p\u003e\n\u003cp\u003eComputed tomography revealed a low-density area in the upper mediastinum suggesting a mediastinal abscess. (a) Coronal section, (b) Axial section at the aortic arch, and (c) Axial section at the bronchial bifurcation.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8646249/v1/c5b333d991a4862757f16f8a.png"},{"id":102739632,"identity":"dd769faf-b97b-4a1d-9370-373c544dbce1","added_by":"auto","created_at":"2026-02-16 07:10:56","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":746162,"visible":true,"origin":"","legend":"\u003cp\u003ePerioperative clinical course.\u003c/p\u003e\n\u003cp\u003e(a) Treatment related to septic shock. The white blood cell counts are shown with solid black lines and C-reactive protein with a dotted line.\u003c/p\u003e\n\u003cp\u003e(b) Treatments for disseminated intravascular coagulation. The platelet counts are shown with solid black lines and prothrombin time-international normalized ratio with a dotted line.\u003c/p\u003e\n\u003cp\u003eDOA: dopamine, NAD: noradrenaline, SBT/ABPC: Sulbactam/Ampicillin, CLDM: clindamycin; MEPM: meropenem; WBC: white blood count; PMX: polymyxin B-immobilized fiber, CRP: C-reactive protein; PT/INR: prothrombin time, international normalized ratio; PLT: platelets\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-8646249/v1/9139f33552d709991b5de30d.png"},{"id":102739623,"identity":"90bea1f7-e73d-4711-9577-e32677fcc4e8","added_by":"auto","created_at":"2026-02-16 07:10:53","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":13387886,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative findings of the first surgery.\u003c/p\u003e\n\u003cp\u003eLeft thoracic cavity. (a) Dorsal to the subclavian artery (b) Ventral side of the left hilum. The aortic arch, left main pulmonary artery, and left superior pulmonary vein are identified. (c) Dorsal side of the left hilum.\u003c/p\u003e\n\u003cp\u003eRight thoracic cavity. (d) An abscess was found at the intersection of the azygos vein and esophagus. (e) Upper gastrointestinal endoscopy performed by a gastroenterologist ruled out esophageal perforation. (f) The abscess has been thoroughly dissected from the superior to the inferior mediastinum.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-8646249/v1/6521417dd55f59c8587f0b02.png"},{"id":102739625,"identity":"cb6232be-7fe1-4fb2-8af2-eebab2c82352","added_by":"auto","created_at":"2026-02-16 07:10:55","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":1949531,"visible":true,"origin":"","legend":"\u003cp\u003eComputed tomography (CT) findings before second surgery.\u003c/p\u003e\n\u003cp\u003eCT revealing the recurrence of a left-sided mediastinal abscess and left empyema. (a) Coronal section, (b) Axial section at the aortic arch, and (c) Axial section at the bronchial bifurcation.\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-8646249/v1/ac51d145f3a8dd272cb7fc70.png"},{"id":102739624,"identity":"ca9caba7-2739-4d08-bca7-11299689b424","added_by":"auto","created_at":"2026-02-16 07:10:54","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":1585132,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative findings at the time of discharge.\u003c/p\u003e\n\u003cp\u003e(a) Chest radiography shows improvement in the enlargement of the superior mediastinum. Computed tomography shows no mediastinal abscess recurrence.\u003c/p\u003e\n\u003cp\u003e(b) Axial section at the aortic arch and (c) Axial section at the bronchial bifurcation.\u003c/p\u003e","description":"","filename":"Figure6.png","url":"https://assets-eu.researchsquare.com/files/rs-8646249/v1/d9c91dfc924aeff3e184cbd4.png"},{"id":102751217,"identity":"ab14f008-d58f-4edc-8d64-2e0b909b9863","added_by":"auto","created_at":"2026-02-16 09:24:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":20283698,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8646249/v1/e26d3730-7037-4c09-a055-56f412fb6b87.pdf"},{"id":102739636,"identity":"cd27c679-e149-4666-a3a0-f48c17cc99ad","added_by":"auto","created_at":"2026-02-16 07:11:02","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":12747,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-8646249/v1/81bfd87e4dfcedf8aad80bf4.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Serious Idiopathic Mediastinal Abscess Associated with Streptococcal Toxic Shock Syndrome Successfully Rescued by Surgery and Intensive Care: A Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003eMediastinal abscesses are rare. Occasional reports of mediastinal abscesses have described those caused by oral or cervical infections \u003csup\u003e1)\u003c/sup\u003e, sternoclavicular joint inflammation \u003csup\u003e2)\u003c/sup\u003e, esophageal perforation \u003csup\u003e3, 4)\u003c/sup\u003e, thoracic surgery\u003csup\u003e5)\u003c/sup\u003e, and bronchoscopy after endobronchial ultrasound-guided transbronchial needle aspiration \u003csup\u003e6)\u003c/sup\u003e. Here, we report a case of an idiopathic mediastinal abscess that was accompanied by septic shock, disseminated intravascular coagulation (DIC), and liver dysfunction. The patient was diagnosed with streptococcal toxic shock syndrome (STSS) based on blood culture results revealing a Group A streptococcal infection. The patient survived as a result of two surgeries and a combination of antibiotics, DIC therapy, and polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP).\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 66-year-old woman with a history of proximal gastrectomy for gastric cancer and right mastectomy for breast cancer called an ambulance complaining of fever, fatigue, and fecal incontinence. She was diagnosed with shock following vital sign measurements revealing a blood pressure of 76/43 mmHg, temperature of 38.7 °C, pulse rate of 126 bpm, and oxygen saturation of 89%. Chest radiography revealed a widened superior mediastinum and atelectasis of the left lower lung field (\u003cstrong\u003eFigure 1\u003c/strong\u003e). Blood and urine test results at the time of transport are shown in \u003cstrong\u003eTable 1\u003c/strong\u003e. Severe inflammation with septic shock, liver dysfunction, renal dysfunction, and coagulation abnormalities were observed. Because shock was diagnosed, the patient underwent contrast-enhanced computed tomography (CT) of the chest, abdomen, and pelvis (\u003cstrong\u003eFigure 2\u003c/strong\u003e). A low-density area was detected in the upper mediastinum, suggesting a mediastinal abscess. An otolaryngologist performed a laryngeal fiberoptic scan, which did not reveal pyorrhea or abscess formation in the laryngopharynx or alveola. No findings suggestive of cellulitis were observed on the body surface. The patient’s progress after admission is shown in\u003cstrong\u003e\u0026nbsp;Table 1\u003c/strong\u003e and \u003cstrong\u003eFigure 3\u003c/strong\u003e.\u0026nbsp;The patient was diagnosed with septic shock due to an idiopathic mediastinal abscess and was immediately admitted to the intensive care unit where therapy with continuous catecholamines and combination meropenem and clindamycin was initiated. Although blood pressure stabilized, blood tests performed the next morning revealed persistent inflammation, and a mediastinal incision and drainage procedure was performed. The Thoracic Surgery, Gastrointestinal Surgery, Emergency Medicine, and Anesthesiology departments discussed treatment; because the primary focus of the abscess was found on the left side of the esophagus, the left side was to be treated first. Furthermore, it was decided that the Gastrointestinal Surgery department would use upper gastrointestinal endoscopy to observe the esophageal lumen and gastroesophageal anastomosis during surgery.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFirst surgery (\u003cstrong\u003eFigure 4\u003c/strong\u003e)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAfter establishing separate lung ventilation, the patient was placed in the right lateral position, and the left thoracic cavity was approached using three-port video-assisted thoracic surgery (VATS). Opaque white pleural fluid, measuring 500 mL, was rapidly aspirated. The entire pleura was noted to be thickened owing to inflammation as the mediastinal pleura was incised along the aortic arch. The left main pulmonary artery and left superior pulmonary vein were identified; however, no abscesses were found in the vicinity. Incisions were made dorsal to the subclavian artery and ascending aorta to allow for pus drainage. The thoracic cavity was thoroughly irrigated and drains were placed dorsal to the left lung apex, anterior mediastinum, and diaphragm. The patient was then placed in the left lateral position, and the right thoracic cavity was approached using the three-port VATS. Similar to the left side, 700 ml of opaque white pleural fluid was removed from the thoracic cavity. An abscess was located at the intersection of the azygos vein and the esophagus, and it was incised and drained. An incision was also made below the carina. During surgery, a gastroenterologist performed an upper gastrointestinal endoscopy, and ruled out esophageal perforation. After thorough irrigation of the right side, drains were placed in the abscess cavity behind the apex of the lung, anterior mediastinum, and diaphragm, and the surgery was completed.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePostoperative course after the first surgery\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePostoperative blood analysis results led to a diagnosis of DIC. After consultation with the hematology department, thrombomodulin, antithrombin, and γ-globulin were initiated. Blood culture results suggested a gram-positive cocci infection, but the possibility of mixed infection could not be ruled out; therefore, PMX-DHP was performed for two days. On postoperative day (POD) 2, blood pressure stabilized, and catecholamines were discontinued. The patient was extubated and weaned from the ventilator on POD 3; however, sputum production was impaired, and a tracheotomy was performed on POD 6. Group A Streptococcus (GAS) was detected in blood cultures, and the patient was diagnosed with septic shock, DIC, and liver dysfunction, meeting the criteria for STSS. Subsequently, white blood cell count gradually increased, and a repeat chest contrast-enhanced CT scan was performed, revealing recurrence of the mediastinal abscess on the cranial and dorsal sides of the aortic arch and the dorsal side of the trachea and bronchi. CT-guided drainage of the abscess was performed on the dorsal side of the left upper mediastinum, followed by a second surgery on POD 12 (\u003cstrong\u003eFigure 5\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSecond surgery\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Separate lung ventilation was established. With the patient in the right lateral position, extensive pulmonary adhesions were observed inside the thoracic cavity using the port (drain insertion site) from the first surgery. Thus, a 15 cm thoracotomy was performed in the third intercostal space, and an approach to the left thoracic cavity was formed. After dissecting adhesions, the cranial and caudal sides of the aortic arch were thoroughly dissected by a cardiovascular surgeon to avoid aortic injuries. The left main bronchus, esophagus, and area inferior to the tracheal carina were thoroughly dissected and irrigated. Drains were placed on the cranial and caudal sides of the aorta, and inferior to the tracheal carina. An optical drain was placed on the lateral side of the latissimus dorsi muscle, and incisions were closed.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePostoperative course\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;All drains were removed by POD 23 after the first surgery. The mediastinal abscess did not recur, and the patient was discharged on POD 33. One year and six months have passed since the second surgery, and the patient is still receiving follow-up at the outpatient clinic without evidence of recurrence (\u003cstrong\u003eFigure 6\u003c/strong\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMediastinal abscesses often occur as a complication of descending necrotizing mediastinitis (DNM) following oral or cervical infection and can progress to sepsis and become fatal \u003csup\u003e7)\u003c/sup\u003e. Mediastinal abscesses often spread aggressively into the mediastinal connective tissues and cause severe illness with sepsis. Emergency surgical treatment, including a wide drainage field, is necessary to prevent critical deterioration. According to the 2023 annual report of the Japanese Association for Thoracic Surgery, 24,024 surgeries were performed for nonneoplastic diseases, of which 134 (0.6%) were for DNM, with a 30-day mortality rate of 4.5% \u003csup\u003e8)\u003c/sup\u003e. Sugio et al. reported that the 30-day and 90-day postoperative mortality rates in 225 patients with DNM were 3.6% and 5.3%, respectively. Furthermore, the 3- and 5-year survival rates were 84.9% and 68.6%, respectively \u003csup\u003e7)\u003c/sup\u003e. They classified infections that were limited to areas superior to the carina level as type I and those that spread to the lower mediastinum as type II. Type II infection was identified as an independent risk factor for 90-day mortality. This patient had no history of preceding infections, such as odontogenic, pharyngeal, cervical, or sternoclavicular joint inflammation. She had not experienced any episodes of fish bone aspiration that could have led to esophageal perforation. Preoperative CT tomography did not reveal any findings suggestive of perforation at the anastomotic site after the proximal gastrectomy. Intraoperative upper gastrointestinal endoscopy revealed no abnormalities. Therefore, an idiopathic mediastinal abscess was diagnosed. The abscess extended from the superior to the posterior mediastinum below the tracheal carina, corresponding to type II in the classification by Sugio et al. \u003csup\u003e7)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSTSS is a very rare complication of GAS infection and is defined with the following clinical manifestations occurring within the first 48 h of hospitalization or, for a nosocomial case, within the first 48 h of illness \u003csup\u003e9, 10)\u003c/sup\u003e: 1) hypotension defined by a systolic blood pressure\u0026thinsp;\u0026le;\u0026thinsp;90 mmHg for adults or less than the fifth percentile by age for children aged\u0026thinsp;\u0026lt;\u0026thinsp;16 years; 2) multi-organ involvement characterized by two or more of the following: a) renal impairment: creatinine\u0026thinsp;\u0026ge;\u0026thinsp;2 mg/dL for adults, greater than or equal to twice the upper limit of normal for age for children, or a greater than two-fold elevation over the baseline level for patients with pre-existing renal disease; b) coagulopathy, including platelets\u0026thinsp;\u0026le;\u0026thinsp;100,000/mm\u003csup\u003e3\u003c/sup\u003e or DIC, defined by prolonged clotting times, low fibrinogen level, and the presence of fibrin degradation products; c) liver involvement, including alanine aminotransferase, aspartate aminotransferase, or total bilirubin levels greater than or equal to twice the upper limit of normal for the patient\u0026rsquo;s age, or in patients with pre-existing liver disease, more than two-fold higher than the baseline level; d) acute respiratory distress syndrome, defined by acute onset of diffuse pulmonary infiltrates and hypoxemia in the absence of cardiac failure, or evidence of pleural or peritoneal effusion with hypoalbuminemia; e) generalized erythematous macular rash that may desquamate; or f) soft tissue necrosis, including necrotizing fasciitis, myositis, and gangrene. This patient experienced septic shock upon emergency transport, and GAS was identified in the blood cultures. After admission, catecholamines were administered to stabilize vital signs, and emergency surgery was performed. Intensive treatment for DIC and sepsis was administered postoperatively. Because the patient was in septic shock at the time of admission and developed liver dysfunction and DIC within 48 hours of admission, we diagnosed the patient with a mediastinal abscess complicated by STSS. Although there is limited evidence regarding PMX-DHP in the treatment of STSS, occasional reports have suggested its usefulness \u003csup\u003e11, 12)\u003c/sup\u003e. The patient's blood pressure increased promptly after use of PMX-DHP, and continuous catecholamine administration was terminated. Therefore, we believe the combination of PMX-DHP with sufficient antibiotic administration and intravenous gamma-globulin therapy contributed to saving the patient's life.\u003c/p\u003e \u003cp\u003eMediastinal abscesses often require emergency surgery, and a treatment strategy must be devised within a limited timeframe. In DNM, the average time from the onset of chest symptoms to mediastinal drainage has been reported to be 1.8 days, and delays in diagnosis and treatment have a direct impact on life prognosis \u003csup\u003e13)\u003c/sup\u003e. There are some points to reflect on in this case. Initial preoperative evaluation suggested a left-sided abscess which found on the left side of the esophagus; however, unlike preoperative imaging results, the abscess was predominantly located in the right posterior mediastinum at the time of the first surgery. Because the left side surgery was performed first, the left mediastinal tissue was destroyed; thus, the subsequent right-sided surgery allowed pus to drip into the left side, possibly leading to the development of the left mediastinal abscess and empyema. As a result, it recurred with a left middle mediastinal abscess and empyema, and a second surgery was necessary to save the patient's life. However, this study suggests that the order of the left-right approaches may reduce the need for reoperation.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eMediastinal abscesses often spread aggressively into the mediastinal connective tissues, cause severe illness with sepsis, and often require emergency surgery. Treatment strategies must be devised within a limited timeframe. Here, we have reported a serious idiopathic mediastinal abscess associated with STSS that was successfully treated with surgery and intensive care using PMX-DHP.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eDIC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;disseminated intravascular coagulation\u003c/p\u003e\n\u003cp\u003eSTSS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;streptococcal toxic shock syndrome\u003c/p\u003e\n\u003cp\u003eCT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;computed tomography\u003c/p\u003e\n\u003cp\u003eVATS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;video-assisted thoracic surgery\u003c/p\u003e\n\u003cp\u003ePMX-DHP\u0026nbsp; \u0026nbsp; \u0026nbsp;polymyxin B-immobilized fiber column direct hemoperfusion\u003c/p\u003e\n\u003cp\u003ePOD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;postoperative day\u003c/p\u003e\n\u003cp\u003eGAS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Group A streptococcus\u003c/p\u003e\n\u003cp\u003eDNM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;descending necrotizing mediastinitis\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Editage (www.editage.jp) for the English language editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYI participated in the surgery, conceived, and conducted the study, and performed the literature search. MI and HU performed the surgeries. MI, SI, NM, and HU supervised the manuscript preparation and revision. All the authors have read and approved the final version of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not require ethical approval from our institution. Informed consent for participation in this study was obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for the publication of this report and its accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eGuo J, Lin L, Zhou H, Yang W, et al. Descending necrotizing mediastinitis caused by Streptococcus constellatus: A case report and review of the literature. Med (Baltim). 2023;102:e33458. https://doi.org/10.1097/MD.0000000000033458\u003c/li\u003e\n \u003cli\u003eNakamoto K, Hagiya H, Hayashi R, et al. Mediastinal abscess induced by Group B Streptococcus. Intern Med. 2023;62:491\u0026ndash;2. https://doi.org/10.2169/internalmedicine.9498-22\u003c/li\u003e\n \u003cli\u003eFu T, Chen J, Xiong B, et al. The first case of esophageal mediastinal fistula after immunotherapy for non-small cell lung cancer: Case report and literature review. J Cardiothorac Surg. 2025;20:9. https://doi.org/10.1186/s13019-024-03207-7\u003c/li\u003e\n \u003cli\u003eZhong S, Wu Z, Wang Z. Successful treatment of fishbone-induced esophageal perforation and mediastinal abscess: A Case report and literature review. Am J Case Rep. 2023;24:e942056. https://doi.org/10.12659/AJCR.942056\u003c/li\u003e\n \u003cli\u003eCao J, Geng M, Huang X, et al. New improved incision-tubing approach for bronchoesophageal fistula with mediastinal abscess after esophagectomy: A case report. Front Surg. 2023;10:1100264. https://doi.org/10.3389/fsurg.2023.1100264\u003c/li\u003e\n \u003cli\u003eIshimoto H, Yatera K, Uchimura K, et al. A serious mediastinum abscess induced by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA): A case report and review of the literature. Intern Med. 2015;54:2647\u0026ndash;50. https://doi.org/10.2169/internalmedicine.54.4465\u003c/li\u003e\n \u003cli\u003eSugio K, Okamoto T, Maniwa Y, et al. Descending necrotizing mediastinitis and the proposal of a new classification. JTCVS Open. 2021;8:633\u0026ndash;47. https://doi.org/10.1016/j.xjon.2021.08.001\u003c/li\u003e\n \u003cli\u003eCommittee for Scientific Affairs, The Japanese Association for Thoracic Surgery, Yoshimura N, Sato Y, Takeuchi H, et al. Thoracic and cardiovascular surgeries in Japan during 2023: Annual report by the Japanese Association for Thoracic Surgery. Gen Thorac Cardiovasc Surg. 2025;73:526\u0026ndash;65. https://doi.org/10.1007/s11748-025-02128-z\u003c/li\u003e\n \u003cli\u003eCase definitions for infectious conditions under public health surveillance (RR-10). Centers for Disease Control and Prevention MMWR Recomm Rep.;p. 1\u0026ndash;55; 1997;46\u003c/li\u003e\n \u003cli\u003eThacharodi A, Hassan S, Vithlani A, et al. The burden of group A Streptococcus (GAS) infections: The challenge continues in the twenty-first century. iScience. 2024;28:111677. https://doi.org/10.1016/j.isci.2024.111677\u003c/li\u003e\n \u003cli\u003eIwashita K, Kobayashi A, Takada A, et al. Primary streptococcal peritonitis treated conservatively－a case report－. Nihon Rinsho Geka Gakkai Zasshi (J Jpn Surg Assoc). 2019;80:798\u0026ndash;803. https://doi.org/10.3919/jjsa.80.798 (in Japanese with English abstract)\u003c/li\u003e\n \u003cli\u003eNakayama A, Sato N, Takai Y, et al. A case of peritonitis associated with streptococcal toxic shock syndrome after colorectal cancer surgery. J Jpn Abd Emerg Med. 2018;38:771\u0026ndash;6. https://doi.org/10.11231/jaem.38.771 (in Japanese with English abstract)\u003c/li\u003e\n \u003cli\u003eMihos P, Potaris K, Gakidis I, et al. Management of descending necrotizing mediastinitis. J Oral Maxillofac Surg. 2004;62:966-72. https://doi:10.1016/j.joms.2003.08.039.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003cp\u003eTable 1 is available in the supplementary files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"idiopathic mediastinal abscess, surgery, streptococcal toxic shock syndrome, septic shock, disseminated intravascular coagulation","lastPublishedDoi":"10.21203/rs.3.rs-8646249/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8646249/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eMediastinal abscesses are relatively rare; however, they have a wide range of causes. We encountered a patient with an idiopathic mediastinal abscess associated with streptococcal toxic shock syndrome due to a Group A streptococcal infection. The patient was successfully treated with two-stage surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation: \u003c/strong\u003eA 66-year-old woman was diagnosed with mediastinal abscess accompanied by septic shock. Infection control was difficult, and the patient underwent incision and drainage of a mediastinal abscess. Postoperatively, the patient was treated using a combination of disseminated intravascular coagulation (DIC) therapy and polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP). Although the shock and DIC resolved, the mediastinal abscess recurred, and a second surgery was required. Blood analysis and culture revealed an idiopathic mediastinal abscess complicated by streptococcal toxic shock syndrome (STSS). One year and six months after the final surgery, the patient has been followed as an outpatient without evidence of recurrence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Here, we report a serious idiopathic mediastinal abscess associated with STSS that was successfully rescued with surgery and intensive care using PMX-DHP.\u003c/p\u003e","manuscriptTitle":"A Serious Idiopathic Mediastinal Abscess Associated with Streptococcal Toxic Shock Syndrome Successfully Rescued by Surgery and Intensive Care: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-16 07:08:35","doi":"10.21203/rs.3.rs-8646249/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision 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