Acute mediastinitis: a severe complication of transdermal therapy in a patient with ischaemic heart disease. A case report Mediastinite acuta: una complicanza grave della terapia transdermica in un paziente con miocardiopatia ischemica. Un caso clinico Federica Faggian, Emanuela Lattuada, Massimiliano Lanzafame, Marco Trevenzoli 1 , Anna Maria Cattelan 1 , Ercole Concia Department of Infectious Diseases, Civile Maggiore-Hospital, B.go Trento, Verona, Italy 1 Department of Infectious Diseases, Padua Hospital, Padova, Italy ■ INTRODUCTION M ediastinitis is a potentially devastating infection involving the structures of the mediastinum. Especially in the past most cases resulted from oesophageal perforation and/or contiguous spread from oropharyngeal foci [1, 2]. Nowadays mediastinitis occurs most fre- quently as a postoperative complication fol- lowing cardiovascular and thoracic surgery or linked to the presence of concomitant risk fac- tors (i.e. HIV infection, intravenous drug use) [3, 4]. We describe an unusual case of deep medias- tinitis following soft tissue infection on the application site of transdermal nitro derivate patches in a patient with ischemic heart dis- ease. ■ CASE REPORT A 62-year-old white man suffering from is- chaemic heart disease was admitted to our In- fectious Disease Department with a 15-day history of fever, pain, progressive swelling and cutaneous erythema of the right paraster- nal border. Because of his medical condition, the patient had been on oral therapy with cardiovascular drugs and transdermal nitro-glycerine patches for the previous two months. Six days before admission the patient had started therapy with roxitromycin (300 mg once a day) as suggested by his own physi- cian, suspecting chestwall cellulitis, without any benefit. On admission physical examination revealed a severely compromised patient, febrile with tachycardia and tachypnoea. Superficial tho- racic examination revealed a subcutaneous mass localized on the right parasternal border at the level of the third intercostal space; a large amount of pus was evacuated by digital pressure from several sites of the localized and fissured erythema. An anterior-posterior chest X-ray film re- vealed a right parasternal lung parenchymal interstitial infiltration and soft tissue echogra- phy showed a non-homogeneous ultrasono- graphic structure near the sternum extending approximately for 7 cm and accompanied by diffused homolateral pectoralis muscle swelling. Blood tests showed leukocytosis (WBC 13,800 cell/mL) with neutrophilia (12,834 cell/mL, 93%) and elevation of inflammatory indexes (ESR 113 mm/h -n.v.: 1-20 mm/h; CRP 22 mg/L -n.v. < 5.0 mg/L ). Microbiological ex- aminations of blood samples and purulent discharge were not diagnostic, perhaps as a Casi clinici Case report Le Infezioni in Medicina, n. 2, 100-102, 2003 102 2003