Bilateral empyema as a rare presentation of Boerhaave syndrome

Abstract Background Spontaneous rupture of the esophagus, also known as Boerhaave syndrome, is a rare condition. It is associated with high morbidity and mortality rates. The poor prognosis of Boerhaave syndrome is mostly due to a delay in diagnosis because of the nonspecific presenting symptoms. Case presentation Herein, we report a case of a 59-year-old patient with diabetes and hypertension who presented with breathlessness, left-sided chest pain, and fever. The initial presentation was consistent with multiloculated empyema and was managed with tube thoracostomy, antibiotics, and empirical antitubercular chemotherapy. During the optimization process for surgery, her disease progressed to sepsis and septic shock. A suspicious finding of contralateral empyema detected on repeat radiography led to obtaining a CT scan of the chest with an oral contrast study. It showed extravasation of oral contrast into the air pockets in the periesophageal region, leading to the diagnosis of Boerhaave syndrome. A cardiothoracic surgery consultation was done, and the team decided on a treatment plan that involved a feeding jejunostomy, VATS decortication, gastrostomy, and esophagectomy to address the patient’s condition. But due to financial constraints, the relatives took the patient to medical college for surgery. This case underscores the diagnostic challenges of Boerhaave syndrome, as its no-specific symptoms, such as chest pain, breathlessness, and fever, initially mimicked more common conditions, such as empyema. The delay in recognizing the correct diagnosis led to the progression of sepsis and septic shock, highlighting the critical importance of considering Boerhaave syndrome in patients with unexplained respiratory symptoms and thoracic pain. Conclusion Bilateral empyema should raise suspicion of Boerhaave syndrome, as early diagnosis and intervention significantly reduce mortality.