Ep 148 – Descending Necrotizing Mediastinitis (DNM): “I Have a Client Who . . .” Pathology Conversations with Ruth Werner

0:00:00.0 Speaker 1: Ruth Werner's best-selling book, A Massage Therapist's Guide to Pathology, is a highly regarded comprehensive resource that sets the standard for pathology education. Written for massage therapy students and practitioners, this ground-breaking resource serves up a comprehensive review of the pathophysiology, signs, symptoms, and treatment of more than 500 diseases and disorders. Learn more at booksofdiscovery.com.

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0:01:15.4 Ruth Werner: Hi, and welcome to "I Have a Client Who... " pathology conversations with Ruth Werner, the podcast where I will discuss your real life stories about clients with conditions that are perplexing or confusing. I'm Ruth Werner, author of A Massage Therapist's Guide to Pathology, and I have spent decades studying, writing about and teaching about where massage therapy intersects with diseases and conditions that might limit our client's health. We almost always have something good to offer even with our most challenged clients, but we need to figure out a way to do that safely, effectively, and within our scope of practice, and sometimes as we have all learned, that is harder than it looks. Today's, "I Have a Client Who... " story comes from a massage therapist in Massachusetts who shares this, "I have a client I will be seeing in a little over a week who has recovered from descending necrotizing mediastinitis. She has been cleared for massage from her medical team, she has had her fingers and toes amputated due to complications of the disease, I believe she also has a large scar on her neck due to surgical intervention. What else should I be aware of or make her aware of upon our first meeting besides medications? I will be seeing her at her home as she currently can't drive."

0:02:42.0 RW: Well, here's something you don't hear about every day, descending necrotizing mediastinitis. Well, we will be calling it DNM just to get us through this conversation. And on follow-up I heard a little more from this massage therapist who says, "Her initial hospitalization was in December 2020. She went to the ER for the worst sore throat she's ever had, and then was admitted and had surgery. She was released from inpatient rehab at the end of March 2021. She is now home and has fully recovered. She also developed sepsis while in the hospital and had to have all of her fingers, I believe just to the intermediate phalanges and toes amputated. I made sure she was cleared by her medical team to receive massage, I know that she is well enough now that she's been visiting with family and friends, and she's been to the beach and so on, and that she'd like to be able to drive again. Thanks for any help you can offer, it's definitely a complicated and interesting situation." Right. Well, right off the bat, I know this massage therapist is on the right track for a couple of reasons, she's done what is possible to be sure that massage is safe, "cleared by her medical team," is a phrase I'm ambivalent about as regular listeners will know.

0:04:05.9 RW: But she's also gathered some information about this client's activities and she already has some ideas about her client's goals, "To be able to drive," even with amputated fingers and toes, and this is a great start. But, as she observes, this is a complicated and interesting situation that definitely deserves some more attention. Descending necrotizing mediastinitis is a rare condition, but I found several case reports about it, these aren't case reports about massage therapy for DNM patients, but they were written by medical teams who found these cases to be remarkable and worth describing to the rest of their profession. And the nice thing about medical case reports is that they're really easy to read, they tend to be short, they're often highly personal, and this makes them a lot more accessible to new research readers than clinical trials or more complicated papers. So, if you're interested and not squeamish, you might wanna read more about this condition from the doctors who treat it, and of course there will be links in our show notes. Let's take this label apart a little bit, descending. Well, that's easy, it means something starts up high and then moves down, in this case, it starts up in the head and moves down into the chest.

0:05:21.2 RW: One of the defining features of DNM, is that it may start as an infection in a tooth or the throat or neck, and this is a really good reason to stay on top of dental health, by the way, because infections of teeth, especially molars in the mandible, are often identified as contributors to DNM. Necrotizing. Well, necrosis, of course is death of tissue. There's a condition called necrotizing fasciitis, you may have heard of, its nickname is flesh-eating bacteria. It's pretty nightmarish because this can begin as just a minor skin infection and quickly become life-threatening. But in this context, it's a little confusing because the causative agent for necrotizing fasciitis is usually a Strep-A infection. But the hallmark of DNM is that it involves multiple types of pathogens, which means it can be difficult to pinpoint it well enough to choose an effective antibiotic. The necrotizing descriptor in this label refers to the death of tissue that occurs with this infection, and again, if you're squeamish, maybe skip the case reports that describe what had to be done to save the life of these patients, let's just say the term frank pus comes up a lot more than we usually look for.

0:06:35.3 RW: And mediastinitis, of course, is inflammation of the mediastinum, that space between the lungs. And I find this word to be confusing, because it's easy to imagine how an organ becomes inflamed, but how does an empty space become inflamed? Well, it just turns out that in this situation, the mediastinum may fill with infection-related material, where it can all interfere with the function of nearby organs. That's no big deal, right? It's just the lungs and the heart. In fact, mediastinitis can mimic pericarditis, inflammation of the outer layer of the serous membrane that encloses the heart, and the secondary damage involved can cause pulmonary edema and maybe embolism and death. Descending necrotizing mediastinitis has a mortality rate between 25% and 40%. Treatment, in addition to antibiotics and other support, involves surgical debridement of the necrotic material, so that's open neck surgery and thoracic drainage. So, how is that aching molar? Are you ready to make an appointment with your dentist now? Well, an infected tooth is not what triggered the situation for our client in this story, her problems began with a sore throat, and I don't have any other details, but it sure makes me wonder if maybe she had strep throat?

0:08:04.7 RW: And evidently, the infection moved down from her throat and invaded tissues, especially the connective tissues that surround the borders of the mediastinum. Huh, so we have an infection that moves along planes of connective tissues. Well, that sounds a lot like necrotizing fasciitis. Exactly how does this greach from the neck to get access to the mediastinum? Well, one of the articles that I read is from the Journal of Thoracic and Cardiovascular Surgery, and they have literally drawn a picture that marks the roots of access for pathogens in the oral pharynx, that's the mouth and throat to you and me, to get down into the mediastinum. This person had complications in her infection that led to the loss of her distal fingers and her toes, again, not the kind of thing we hear about every day, but it happens with some regularity in the context of a situation called sepsis and possibly septic shock. Now, I was really interested that I happened to get this "I Have a Client Who... " story this week, because I just finished writing an article for massage and body work on sepsis, the hidden crisis a couple of weeks ago.

0:09:15.0 RW: And in the process of working on that project, I learned a lot more about how a generalized infection can lead to complications like amputation and more. So, here's a short version, but I recommend that you read the article and also watch the video where I talk about two massage therapists who both had sepsis last year and who shared their stories with me. Sepsis, you might know, is a situation in which an infection has complicated to a potentially life-threatening problem. We used to think that sepsis was the result of system-wide, super-aggressive pathogenic invasion. And by we, I mean I, and by used to, I mean, up to a couple of weeks ago. Pathogens associated with sepsis could be viruses or fungi, but bacteria are the usual suspects. But, here's what we have learned, which is to say, here's what I have learned. The infection part of sepsis is only one part of the problem, a much bigger issue is the inflammatory response to the infection and our immune system activity that goes with it. People with sepsis can experience a massive system-wide inflammatory over-reaction to an infection, and this causes excessive blood clotting and a dangerous drop in blood pressure that can lead to organ failure, and that is the result of septic shock.

0:10:44.5 RW: Either or both of these, sepsis and septic shock, can cause poor perfusion of the extremities, that means cells die from lack of oxygen and nutrients, and this can lead to gangrene and a need for amputation. I wonder if any of this is ringing any bells for you? Because, it is the same combination of factors; an infection, a normal aggressive immune system response and a totally off the charts, out of proportion inflammatory response that we see in really severe life-threatening and sometimes life-ending infections with a virus that has been on our minds; SARS-CoV-2, the causative agent of COVID-19. But wait, there's more. There's a condition called post-sepsis syndrome, it involves brain fog and loss of cognition, poor stamina, fatigue, pain, muscle weakness and wasting PTSD symptoms, chest pain, shortness of breath, insomnia, depression and anxiety. What does that sound like? Gosh, that sounds a lot like long COVID. And like long COVID, we don't really know what portion of people who have sepsis go on to develop this chronic, long-term consequence. So, this client had a sore throat, probably from a bacterial or viral infection, and then the infection descended into her mediastinum and took up residence there, causing massive tissue damage and tissue death.

0:12:22.8 RW: And she had a big inflammatory reaction and developed sepsis with blood clotting and poor tissue perfusion, she had to have surgery on her neck to remove the necrotic material, and her fingers and toes had been so damaged that they had to be amputated. And this whole process involved four months of hospitalization and rehab. Now she's home and she's beginning to be more active and she'd like to receive massage. What questions do you have for this client? Well, here are some of mine; how often are you still seeing your medical team and would it be okay if I consulted with them, if that seems helpful? Are you still working with a physical therapist or an occupational therapist? If yes, what are their goals for your work together and can I consult with them to make sure we're all on the same page? What medications are you taking and what side effects do they have? Are you having any issues with post-sepsis syndrome, and what does that mean for you? Please describe your activities of daily living, so I have a clear idea of how much physical toleration you have, and I know you'd like to be able to drive again, what other goals do you think I could help you with? And how does the amputation of your toes affect your comfort while walking, are there repercussions there that massage therapy might be helpful for?

0:13:48.9 RW: And that's just the beginning of questions I'd like to ask this person, if these answers reveal that the client has the capacity to adapt to changes that massage brings about, and if her amputations have healed well and they're not causing a lot of pain and they're not irritated by touch, then I predict that massage therapy could offer an amazing contribution to this client's continuing recovery. Recovering from descending necrotizing mediastinitis is no small feat, and this person deserves every chance to explore what her function can be in her post-sepsis life. I hope this massage therapist dives into helping her with gusto and optimism, so she can look forward to recovering absolutely as much function as possible. Hey, everybody, thanks for listening to "I Have a Client Who... " pathology conversations with Ruth Werner. Remember, you can send me your "I Have a Client Who... " stories to ihaveaclientwho@abmp.com, that's ihaveaclientwho, all one word, all lowercase @abmp.com. I can't wait to see what you send me and I'll see you next time.