Right-Sided Hydropneumothorax as a Presenting Symptom of Boerhaave's Syndrome (Spontaneous Esophageal Rupture)

Abstract

Boerhaave's syndrome, or spontaneous esophageal rupture, is a rare condition that classically presents with Mackler's triad of vomiting, sub-cutaneous emphysema, and severe sudden onset of chest pain and requires immediate medical attention. Approximately 90% of the perforations occur at the left lateral aspect of the distal esophagus, causing a left-sided pleural effusion. Less than 10% of patients have bilateral effusions, and few patients have a right-sided pleural effusion only. We present the case of a 59-year-old man with spontaneous esophageal rupture. His clinical presentation is of interest since he had no inciting event for spontaneous esophageal rupture and had a delayed presentation with a right-sided hydropneumothorax. B oerhaave's syndrome, or spontaneous esophageal rupture , is a life-threatening condition that requires prompt diagnosis and treatment. Delayed diagnosis may result in serious complications, including mediastinitis, pneu-monitis, pericarditis, empyema, and death. We report an atypi-cal presentation of Boerhaave's syndrome with no vomiting, with progressive right-sided chest pain and shortness of breath of 2 weeks' duration, and with a right-sided hydropneumothorax. CASE REPORT A 59-year-old man with a history of hypertension presented with worsening right-sided chest pain and progressive shortness of breath of 2 weeks' duration. Th e patient had reported mild constant right-sided chest pain over the past year. Th e chest pain was pleuritic in nature. He denied fevers, chills, productive cough, nausea, and vomiting. Th e patient had a history of upper gastrointestinal bleeding 4 months prior to presentation while taking meloxicam. He underwent esophagogastroduodenoscopy, which showed benign esopha-geal ulcers in the middle thoracic esophagus from 26 to 29 cm and in the distal esophagus from 33 to 36 cm, as well as chronic gastritis. He took oral omeprazole 20 mg twice a day and stopped taking meloxicam. He started to take one or two 7.5 mg tablets of meloxicam a day to relieve the chest pain without taking omeprazole for 1 week before his current presentation. He denied refl ux symptoms, a history of heavy lifting or straining, a history of chest trauma, peptic ulcer disease, or alcohol or steroid use. His blood pressure was 114/66 mm Hg; heart rate, 123 beats/ min; respiratory rate, 21 breaths/min; and temperature, 36.7°C (98°F). His body mass index was 20.3 kg/m 2. Th e jugular veins were not distended. Breath sounds were decreased in the right lower fi eld, with corresponding dullness on percussion. Th ere was no murmur, subcutaneous emphysema, or Hamman's crunch. Th e abdomen was soft without tenderness. Th e bowel sounds were normal. Initial laboratory tests revealed the following: white blood cell count, 26,570/μL with 95% polymorphonuclear cells; hemoglobin, 10.7 g/dL; blood urea nitrogen, 31 mg/dL; creati-nine, 0.9 mg/dL; and albumin, 2.7 g/dL. All other laboratory results were unremarkable. His initial chest radiograph revealed a right-sided hydropneumothorax (Figure 1). A thoracostomy tube was placed into the right chest, resulting in the drainage of 1 L of brownish purulent material. Pleural fl uid analysis showed a pH of 7.2. Gram stain of the pleural fl uid showed a few white blood cells; many Gram-positive cocci in pairs, chains, and clusters; moderate Gram-positive rods; few Gram-negative rods; and few yeast. Computed tomogra-phy (CT) of the chest revealed moderate right pleural eff usion, small right pneumothorax, consolidation/atelectasis in the right lower lobe with air bronchograms, and thickening of the distal esophagus and gastroesophageal junction. Th e patient had video-assisted thorascopic surgery 2 days after admission. Gastrointestinal contents were found in the pleural cavity. At this point, the diagnosis of Boerhaave's syndrome was suspected, and the procedure was converted to an open thoracotomy. Th e patient had a hiatal hernia and a distal esophagus perforation measuring approximately 2.5 cm. A dis-tal esophageal resection and gastrostomy tube placement were performed. Th e biopsy report of the distal esophagus showed intestinal metaplasia and ulcer without dysplasia or malignancy. Th e patient's postoperative course was complicated by sepsis and acute renal failure. Th e pleural culture grew Citrobacter freundii; blood cultures were negative. He was continued on meropenem and fl uconazole. His renal function returned to Right-sided hydropneumothorax as a presenting symptom of Boerhaave's syndrome (spontaneous esophageal rupture)