Boerhaave's Syndrome: An Unusual Geriatric Presentation

Abstract

Boerhaave's syndrome (BS) is a non-iatrogenic spontaneous esophageal perforation that, if not appropriately recognized and managed, can cause localized infections such as mediastinitis, pneumonia, and empyema, as well as systemic infections with significant morbidity and mortality rates. An autonomous 83-year-old male presented to the emergency department with a three-day history of behavioral changes. Three days earlier, the patient had a self-limited episode of cough, nonspecific thoracalgia, palpitations, prostration, and pallor. On physical examination, he was alert but had temporal disorientation, hypoxemia, and pulmonary auscultation with abolished breath sounds in the middle third of the left chest. Laboratory tests showed hypoxemia, elevated C-reactive protein (28.2 mg/dL), and D-dimer (3.28 µg/mL). A chest X-ray revealed periaortic small bubbles, left atelectasis, and left pleural effusion. Computed tomographic angiography of the chest showed infra-carinal esophageal rupture, small bubbles of the anterior pneumomediastinum, and a loculated left pleural empyema. Mediastinitis and empyema due to BS were assumed. He underwent left thoracic drainage, broad-spectrum antibiotics, and the placement of a surgical esophageal prosthesis. He was discharged after 48 days. The condition known as BS is frequently misdiagnosed, mostly as a result of the lack of a preexisting pathological background and the wide array of potential symptoms that may manifest. The diagnosis in this particular case was rendered particularly complex due to the combination of an unusual presentation and a delayed seeking of medical attention. Against all expectations, our patient was successfully treated.

Keywords: boerhaave's syndrome; empyema; endoscopic oesophageal prosthesis; haemorrhagic shock; pneumomediastinum; spontaneous oesophageal perforation; surgical oesophageal prosthesis.

Figure 1. Chest X-ray with periaortic small air bubbles (pneumomediastinum) marked by the yellow arrow, atelectasis, and left pleural effusion (green arrow)

Figure 2. Computed tomographic angiography

Yellow arrow: Infra-carinal esophageal rupture with pneumomediastinum, Green arrow: Left pleural empyema, Orange arrow: Carina