Boerhaave Syndrome Presenting as Tension Pneumothorax

Abstract

Tension pneumothorax is a rare and potentially life-threatening clinical complication. A 43-year-old Caucasian woman with type 1 diabetes mellitus presented with nausea and retching and examination revealed dehydration. Laboratory parameters were consistent with a diagnosis of diabetic ketoacidosis, which responded to therapy. Suddenly, 30 hours later, she developed cardiorespiratory compromise due to a tension pneumothorax. After emergent decompression and catheter placement, computerized tomographic scan of the chest demonstrated esophageal-pleural fistula confirming Boerhaave syndrome as the etiology for the pneumothorax. The patient underwent emergent esophagectomy with pleural washout with a subsequent gastric pull-up surgery. Boerhaave syndrome frequently presents atypically with chest pain, dyspnea, and nausea. It communicates with the left pleural space in 80% to 90% of cases, but <5% of cases involve the right pleural cavity. Unexplained and rapidly progressive pleural effusions have been associated with this entity. Only 4 cases of Boerhaave syndrome causing tension pneumothorax have been reported in the literature so far.

A Rare Case of Boerhaave Syndrome Presenting with Right Tension Pneumothorax and Review of the Literature

“…Boerhaave syndrome has been recognized in the medical literature to present in unusual ways, however presentation with tension pneumothorax is exceedingly rare. There is only one previously reported case in North America, and 5 cases worldwide [10][11][12][13][14]. In contrast to our case, all of these cases reported history of preceding abdominal pain and vomiting, alerting the physicians to the possibility of esophageal rupture as the source of the pneumothorax.…”

Boerhaave's syndrome – tension hydropneumothorax and rapidly developing hydropneumothorax: two radiographic clues in one case

“…Therefore, tension pneumothorax in these cases should be interpreted as tension hydropneumothorax. In our case, the first chest radiograph only showed a small pneumothorax because lung markings were clearly visible, and the visceral edge in the upper left hemithorax could be identified with the great caution. Therefore, if we recognized tension hydropneumothorax on chest radiograph at the time of admission, Boerhaave's syndrome should be investigated and established before the patient worsens.…”

Tension hydropneumothorax as the initial presentation of Boerhaave syndrome

“…Boerhaave syndrome may also be suspected based on mediastinal widening, pneumothorax, hydrothorax, hydropneumothorax, mediastinal shift, and/or subcutaneous emphysema [ 8 ]. Esophagram or CT scan with water-soluble oral contrast is the gold standard for diagnosing esophageal perforation [ 2 , 3 ]. However, due to the high false negative rate of the contrast esophagram (15–25%) and tenuous nature of esophageal rupture, chest CT is a more appropriate modality for diagnosis.…”

“…However, due to the high false negative rate of the contrast esophagram (15–25%) and tenuous nature of esophageal rupture, chest CT is a more appropriate modality for diagnosis. Extraluminal and/or mediastinal free air are the most common findings, occurring in 92% of cases [ 2 , 3 ]. Additional chest CT findings that are suspicious, but not specific for esophageal rupture include esophageal thickening, mediastinal fluid, or pleural effusions [ 9 ].…”

“…Mackler's triad, consisting of chest pain, vomiting, and subcutaneous emphysema represents a classic presentation. However, Mackler's triad is only present in about 5% of case, with chest pain being the most common feature [ 2 , 3 ]. Boerhaave syndrome itself is rare, with an annual incidence of 3.1 per 1,000,000 [ 4 ].…”