A 32-year-old man comes to the emergency department with intense, midline chest pain and diaphoresis of 4 hours duration. Prior to the onset of pain, he developed nausea and recurrent vomiting after returning from a party. His medical conditions include HIV infection, alcohol use disorder, and alcoholic hepatitis. The patient uses cocaine regularly and does not take his medications regularly. Temperature is 38.3 C (101 F), blood pressure is 100/60 mm Hg, pulse is 120/min, and respirations are 28/min. Examination shows injected conjunctivae and bilateral dilated pupils. Breath sounds are present on the right but diminished on the left. Heart sounds are normal. Chest x-ray demonstrates a widened mediastinum and moderate left-sided pleural effusion. ECG shows sinus tachycardia. The pleural fluid is found to be a yellow exudate with high amylase content. Which of the following is the most likely diagnosis in this patient?
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This patient has midline chest pain, fever, and a widened mediastinum in the setting of protracted vomiting, which are most concerning for esophageal perforation (EP).
Effort rupture of the esophagus (Boerhaave syndrome) can occur with repeated vomiting, particularly when the patient resists the vomiting reflex. The perforation allows gastrointestinal contents to leak from the esophagus into the mediastinum (causing widened mediastinum on chest x-ray) and/or into the pleural space (causing pleural effusion). The inflammatory gastrointestinal contents often cause severe chest pain and a systemic inflammatory response (eg, fever, tachycardia) that can quickly progress to septic shock and death.
Visualization of contrast extravasating from the esophagus into surrounding tissues, either by esophagography or CT scan with water-soluble contrast (barium is more inflammatory), confirms the diagnosis. Pleural fluid analysis is not required to confirm EP, but if performed, typically shows low pH and very high amylase (>2500 IU/L from leaked saliva) and may show food particles. Surgical consultation should be obtained as soon as the diagnosis is made because most perforations require emergent operative debridement and repair.
(Choice A) Acute pancreatitis can cause a unilateral, left-sided, exudative pleural effusion with a high amylase concentration (due to high serum amylase levels). However, pancreatitis presents more classically as epigastric pain radiating to the back rather than chest pain and would not cause mediastinal widening on chest x-ray.
(Choice B) Severe chest pain accompanied by a widened mediastinum and unilateral pleural effusion (possible hemothorax) is concerning for aortic dissection in a patient actively using cocaine (a risk factor), as in this patient with injected conjuctivae and dilated pupils. However, aortic dissection usually has associated findings such as pulse/blood pressure variation (eg, >20 mm Hg blood pressure difference between the extremities), and fever is uncommon.
(Choice C) The patient is at risk for aspiration from protracted vomiting. Although fever, tachypnea, and pleural effusion (possible parapneumonic effusion) are concerning for aspiration pneumonia, severe chest pain is not typical, and infiltrates would be expected on chest x-ray. In addition, pleural fluid analysis of a parapneumonic effusion would not be expected to show elevated amylase.
(Choice E) Severe chest pain in the setting of cocaine use (coronary vasospasm) is concerning for myocardial infarction. However, myocardial infarction is less likely given the lack of ischemic changes on ECG; also, it would not account for this patient's unilateral pleural effusion or widened mediastinum on chest x-ray.
Educational objective:
Effort rupture of the esophagus (Boerhaave syndrome) may occur during protracted vomiting. Chest x-ray may show leaked esophageal fluid collecting in the mediastinum (mediastinal widening) or pleural space (pleural effusion). Pleural fluid analysis may show low pH and very high amylase (>2500 IU/L). Confirmation with esophagography or CT scan using water-soluble contrast should prompt emergent surgical consultation.