1. A Case of Boerhaave’s Syndrome

GR Mahadevan, R Tolstoy, T Saravanan, K Jayachandran
PSG IMS and R, Coimbatore – 4.

Thirty six year old male, smoker, alcoholic, admitted on 7.5.2007 at 20.45 hrs – with sudden onset of Central Chest Pain, compressing type with radiation to the back, associated with profuse sweating and breathlessness. No associated nausea (or) vomiting. Clinical examination revealed Tachycardia and crepitations in left infrascapular area, and no other signs. Suspected to have Acute Coronary Syndrome and started treatment. Serial ECG showed ST depression in V4, V5, V6 and ‘T’ wave inversion in LII, LIII, aVF with sinus tachycardia. On 8.5.2007 the dyspnoea got worsened. Repeat X-ray chest showed left pleural fluid. ICD was introduced, drained 800 ml of pus. Because of the persistent chest pain, tachycardia, CT Thorax with contrast was done, which revealed 4 mm Rent in the Left lateral wall of distal esophagus with extravasation of oral contrast into left pleural cavity. The final diagnosis of esophageal tear with mediastinitis with left pyothorax was made. Retrospective reviewing of CXR taken on 7.5.2007 showed a thin line of Air Column (longitudinal) in the left side of mediastinum which was overlooked. The uncommon presentation was absence of GI symptoms like nausea and vomiting before the onset of chest pain. This case report reveals that a careful interpretation of Xray chest will help in the diagnosis of pneumomediastinum which can masquerade as Acute Coronary Syndrome.