Diagnostic Dilemma: Mediastinal Abscess Imitating Lymphadenitis from Esophageal Fistula

fever was reported.She described a marked increase in respiratory distress over the preceding 24 hours.Her medical history was significant for recent surgical correction of a small perimembranous ventricular septal defect (VSD) in 2024.She also had a history of TEF surgical repair performed in the neonatal period, at 4 days of life.On examination, she was afebrile and hemodynamically stable (blood pressure 110/70 mm Hg) but tachycardic (pulse 125 beats per minute) with an oxygen saturation of 90% on room air.Auscultation revealed bilateral wheezing.She was promptly evaluated with a high-resolution computed tomography (HRCT) of the thorax, as shown in Figure 1, revealing a large right paratracheal nodal mass IntroductIonThe mediastinum, the central compartment of the thoracic cavity, contains vital structures such as the heart, great vessels, trachea, and esophagus.While typically well-protected, it remains a potential space vulnerable to infections or fluid collections.Mediastinal masses are a relatively common radiological finding and encompass a broad differential, including neoplasms, lymphadenopathy, cysts, and vascular anomalies. 1 In contrast, mediastinal abscesses are rare and typically present with systemic signs such as fever, chest pain, or sepsis. 2 When they do occur, they are usually secondary to trauma, esophageal perforation, postoperative complications, or spread from adjacent infections.We describe a case that defies these typical patterns-a young woman with an apparently routine presentation of a mediastinal mass, ultimately diagnosed as a mediastinal abscess.Notably, this abscess occurred in the absence of fever or systemic symptoms, and its origin was traced back to a suspected esophageal leak, likely a late complication of childhood tracheoesophageal fistula (TEF) repair.This case underscores the diagnostic challenges posed by atypical presentations of uncommon pathologies, especially in patients with remote surgical histories. case descrIptIonA 27-year-young female presented to the emergency department with a 3-day history of progressively worsening right-sided chest pain and exertional dyspnea.The chest pain was continuous, severe, and unrelated to respiratory effort.No associated cough or