A Rare Case of Ascending Necrotizing Mediastinitis following Perforated Appendicitis: A Case Report

INTRODUCTION: Necrotizing fasciitis (NF) is a rapidly progressing soft-tissue infection associated with high mortality. While descending necrotizing mediastinitis (DNM) from cervical infections is well characterized, ascending necrotizing mediastinitis (ANM) originating from intra-abdominal sources is extremely rare. CASE PRESENTATION: A 66-year-old woman presented with right flank pain, fever, and leukocytosis. CT imaging revealed a pericecal abscess and retroperitoneal air associated with perforated appendicitis. Emergency right hemicolectomy with diverting ileostomy and extensive debridement were performed. Postoperatively, the patient developed empyema and mediastinitis due to retroperitoneal infectious spread through the diaphragm. A second-look operation confirmed progressive retroperitoneal necrosis without anastomotic leakage. Given the patient's stability and prior surgical burden, mediastinitis was successfully managed with percutaneous catheter drainage (PCD). She made a full recovery following prolonged wound care and vacuum-assisted closure therapy. CONCLUSIONS: This case highlights an exceedingly rare form of ANM originating from appendicitis. In selected patients with adequate source control and clinical stability, minimally invasive management such as PCD may be an appropriate alternative to aggressive mediastinal surgery.