A 67-year-old man is brought by his daughter to the emergency department with fever, back pain, and chest pain. The pain is constant and severe, and it does not vary with respirations. The patient has severe dysphagia due to esophageal achalasia, for which he frequently self-induces vomiting to relieve the sensation of choking. Other medical conditions include hypertension, peripheral vascular disease, and a 4-cm abdominal aortic aneurysm. He has a 30-pack-year smoking history and quit 5 years ago. The patient uses alcohol, usually during the weekends. He also has had a 5-kg (11-lb) weight loss over the past year. On examination, the patient is in distress due to pain. Temperature is 38.7 C (102 F), blood pressure is 100/60 mm Hg, pulse is 118/min, and respirations are 24/min. There is dullness to percussion and decreased breath sounds in the left lung base. Heart sounds are normal. Chest x-ray reveals left-sided pleural effusion; no additional infiltrates are seen. Which of the following is the most likely diagnosis?
Esophageal perforation | |
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This patient has chest/back pain, fever, and pleural effusion in the setting of self-induced vomiting, most concerning for esophageal perforation. Effort rupture of the esophagus (Boerhaave syndrome) can occur with repeated vomiting, particularly when the patient resists the vomiting reflex. Patients usually have severe chest pain (and/or back pain given the esophagus's posterior location) and a systemic inflammatory response (eg, fever, tachycardia). If esophageal contents leak through the perforation into the pleural space, pleural effusion results, usually on the left due to intrinsic weakness in the left posterolateral aspect of the distal intrathoracic esophagus.
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. Intravenous, broad-spectrum antibiotics and proton pump inhibitors should be administered, all oral intake restricted, and emergent surgical consultation obtained. Most perforations will require operative debridement and repair.
(Choice A) Acute pancreatitis can cause a unilateral, left pleural effusion and fever in severe cases. Associated pain may radiate to the back but typically originates in the epigastrium, not the chest.
(Choice B) Severe chest/back pain is concerning for aortic dissection in a patient with multiple risk factors (hypertension, preexisting aortic aneurysm). However, aortic dissection often has associated findings of new heart murmur (aortic regurgitation from retrograde dissection) or pulse/blood pressure variation (eg, >20 mm Hg blood pressure difference between the extremities). Fever is uncommon.
(Choice C) This patient is at risk for aspiration pneumonia from self-induced emesis. Although fever, tachycardia, and diminished left breath sounds are concerning for pneumonia, severe chest/back pain is not typical, and infiltrates (possibly with effusion) would be expected on chest x-ray.
(Choice D) Hypertension, smoking, and likely coronary artery disease (given history of peripheral vascular disease) increase this patient's risk of congestive heart failure. Although congestive heart failure may present with pleural effusion, a history of progressive dyspnea and signs of peripheral congestion (eg, elevated jugular venous pulse, peripheral edema) are typically present. Fever is uncommon.
(Choice F) The patient's smoking history and weight loss are concerning for lung cancer. Lung cancer may cause malignant pleural effusion, but associated pain is typically dull/aching and fever is uncommon. Restricted food intake because of achalasia can explain the patient's slow weight loss.
Educational objective:
Effort rupture of the esophagus (Boerhaave syndrome) can occur with vomiting and may cause unilateral pleural effusion from leaked esophageal contents. Confirmation with esophagography or CT scan using water-soluble contrast should prompt emergent surgical consultation.