Assistant Professor University of Alabama Birmingham, United States
Introduction: A 57-year-old male with GERD and alcohol use disorder presented with facial swelling, initially suspected as an allergic reaction, and was intubated for acute respiratory failure.
Description: On arrival, the patient was febrile and hypotensive. Initial chest xray revealed bilateral hydropneumothoraces, thought to be from traumatic intubation, leading to bilateral chest tube placement. The pleural fluid studies were consistent with an exudative process with pH < 6.79. Broad spectrum antibiotics were started to treat the patient for presumed empyema. Following extubation, a FEES was performed and the FEES fluid emerged into the bilateral chest tubes. Elevated pleural fluid amylase and esophagram confirmed a perforation at the GE junction with contrast extravasation into the left pleural space. Advanced endoscopy confirmed Boerhaave’s syndrome, leading to esophageal stent placement with endoscopic suturing. At a later date thoracic surgery performed VATS decortication. The initial facial swelling was in fact subcutaneous emphysema from esophageal rupture rather than an allergic reaction. The original esophageal tear was thought to have occurred after an intense vomiting episode.
Discussion: This case highlights the diagnostic challenges of Boerhaave’s syndrome, especially when initial symptoms are non-specific. Diagnostic anchoring on initial findings can mislead, as seen in this case with the misattribution of facial swelling to an allergic reaction and misattribution of pneumothoraces to traumatic intubation. The differential diagnosis of subcutaneous emphysema is wide and should be explored when identified. Recognizing Boerhaave’s, despite its rarity, and timely multidisciplinary intervention were crucial for patient recovery.
