malignant tumors are associated with 2.3% of cervical abscesses caused by cellulitis and 
 are associated with abscesses in the head and neck region resulting from odontitis , 
 peritonsillitis or cervical cellulites . moreover , these ailments sometimes lead to descending necrotizing mediastinitis ( dnm ) as a 
 life - threatening complication . dnm in turn can be followed by severe complications , such as 
 tracheal rupture , vascular compression , 
 septic shock and multiorgan failure , 
 including pneumonia and cardiac or renal failure . this is especially true for 
 patients with immune system disorders such as those caused by diabetes mellitus . on the 
 other hand , esophageal perforation caused by dnm has been only reported in a single 
 retrospective study by roccia et al . , and the details remain unclear . here , we present the case of a 
 78-year - old man with dnm caused by deep neck infection , which was accompanied with two large 
 esophageal fistulas and multiple gastric ulcers . a 78-year - old man presented at our hospital with elevated body temperature , dysphagia and 
 an abnormal sensation on the right side of his neck , all of which had persisted for 7 days . the patient had previously been administered broad - spectrum intravenous antibiotics for 2 
 days by another physician , who made a diagnosis of right peritonsillitis and referred the 
 patient to our hospital . the patient s medical history consisted of only hyperlipidemia , 
 which was diagnosed when he was 60 years old and is being treated with oral medication , and 
 angina pectoris , which was diagnosed when he was 75 years old and was being treated with 
 nitroglycerin . , we did not detect right peritonsillitis , a neck mass , neck 
 erythematous swelling or neck tenderness , though we did detect a small amount of serous 
 fluid in a piriform sinus . the laboratory findings were as follows : wbc count , 9,050 
 cells/l with 93% segmental neutrophils ; c - reactive protein , 18.39 mg / dl ; 
 k , 5.04 meq / l ; hb , 13.4 g / dl ; and bun , 21 mg / dl . at that time , the patient was administered 
 fluid , hydrocortisone , cefazolin ( cez ) and clindamycin ( cldm ) while he abstained from eating 
 any food . on his second day in hospital , performed on day 3 revealed an abscess extending from the right 
 parapharyngeal space to the thoracic level of the left esophagus ; the lesion progressed from 
 the right to left side at the laryngeal level ( figure 
 1afigure 1 . it is supposed that 
 the abscess descended across from right to left at the laryngeal level ( fig . the pharyngeal abscess descended to 
 the breastbone level via the left side of the esophagus . the vertical length of the lesion was more than 10 cm ( figure 1b ) . based on the patient s history and the radiological 
 findings , dnm , probably following peritonsillar cellulitis , was diagnosed . the cez and cldm 
 were replaced by carbapenem ( papm / bp ) with human gamma globulin , and the patient markedly 
 improved by day 7 ; his wbc count declined to 6,620 cells/l ; c - reactive 
 protein was down to 2.25 mg / dl ; and his rbcs , hb and ht had declined to 330 cells / ml , 10.7 
 gm / dl and 31.5% , respectively . an oral proton pump inhibitor taken orally was added to the 
 patient s medication , and the hydrocortisone was tapered until it was discontinued on day 
 9 . it is supposed that 
 the abscess descended across from right to left at the laryngeal level ( fig . the pharyngeal abscess descended to 
 the breastbone level via the left side of the esophagus . a gastrointestinal endoscopic examination performed on day 9 revealed two large esophageal 
 fistulas , respectively , located between the esophageal orifice and broncho - aortic 
 constriction ( figure 2figure 2 . there were two major fistulas on the left side of the 
 esophagus , 15 and 20 centimeters , respectively , from an incisor ( figure corresponding 
 to the upper sides of the fistulas ) . ) . also detected were three ulcers , respectively , situated on the posterior wall of 
 the body and the anterior and posterior walls of the greater curvature of the stomach ( figure 3figure 3 . three ulcers located on posterior wall of body and 
 anterior and posterior walls of the greater curvature of the stomach showed no 
 petechial hemorrhage and no erosion circumferentially . ) . when computed tomography and direct gastrointestinal endoscopic examination were 
 subsequently performed on days 22 and 28 , no abscesses were detected , and healing of the 
 gastric ulcers was at the h2 stage . moreover , pathological examination revealed no malignant 
 cells in either the esophagus or stomach ( figure 
 4figure 4 . there were no malignant cells in the 
 gastric mucosa and the gastric ulcers were diagnosed as being at the h2 stage . ) .   esophageal findings on day 9 . there were two major fistulas on the left side of the 
 esophagus , 15 and 20 centimeters , respectively , from an incisor ( figure corresponding 
 to the upper sides of the fistulas ) .   gastric findings on day 9 . three ulcers located on posterior wall of body and 
 anterior and posterior walls of the greater curvature of the stomach showed no 
 petechial hemorrhage and no erosion circumferentially . there were no malignant cells in the 
 gastric mucosa and the gastric ulcers were diagnosed as being at the h2 stage . an elevated wbc count with a high concentration of segmental neutrophils accompanied by 
 elevated c - reactive protein and hyperkalemia suggested a serious infection in this patient . 
 on day 3 , dnm was diagnosed based on ct findings and the absence of any obvious neck 
 abnormality , which is consistent with the earlier reported findings of endo et 
 al .. although surgical 
 drainage is recommended for treatment of dnm6 , 
 7 ) , we chose a conservative treatment 
 consisting of broad - spectrum intravenous antibiotic therapy because the thoracic abscess was 
 thought to have caused the fistula into the esophageal lumen . although mediastinitis 
 secondary to esophageal perforations is associated with a high rate of mortality , 
 broad - spectrum intravenous antibiotic therapy is reportedly a satisfactory 
 approach . on day 9 , direct upper gastrointestinal endoscopic examination revealed two large 
 esophageal fistulas and three gastric ulcers that perhaps formed as a result of the rupture 
 of submucosal lesions . when multiple ulcers appear in both the pharynx and esophagus , double 
 cancer or advanced esophageal cancer with multiple gastric lesions should be considered . other differential diagnoses include infectious diseases such as tuberculosis and 
 cytomegalovirus infection , systemic diseases such as sarcoidosis and benign tumors such as 
 gastrinoma . in the present case , although the origins of deep neck infections remain unknown in 22% to 
 50% of patients , despite detailed examination1 , 
 10 , 11 ) , in the present case , we were able to diagnose dnm following 
 peritonsillitis that penetrated into the esophagus and produced multiple gastric ulcers . that said , close follow - up is required in this case because deep neck infections are 
 sometimes associated with occult tumors . in addition , the mechanism by which dnm led 
 to formation of the esophageal fistulas and gastric ulcers remains unknown .
here , we present the case of a 78-year - old man with a deep neck infection that caused 
 descending necrotizing mediastinitis that extended from the pharynx to the stomach and was 
 accompanied by two large esophageal fistulas and multiple gastric ulcers . 
 we believe that 
 the series of lesions were the signs of a hidden carcinoma .