Atypical Presentation of Boerhaave Syndrome with Left Shoulder Pain as the Initial Manifestation: A Case Report

BACKGROUND This report describes a rare spontaneous esophageal rupture presenting as left shoulder pain. Spontaneous transmural rupture, or Boerhaave syndrome, is a surgical emergency with high morbidity and mortality but is often missed due to atypical signs. Mackler's triad of vomiting, acute chest pain, and subcutaneous emphysema raises concern for this diagnosis but appears in only about 50% of cases, emphasizing early recognition and high suspicion in atypical presentations. CASE REPORT We present a rare case of an Asian man in his 90s with hypertension presenting with left shoulder pain and chest discomfort, accompanied by a mild cough. Physical examination revealed that a crunching sound known as Hamman's sign was heard synchronous with the heartbeat. The chest X-ray showed air in the neck's soft tissue. Computed tomography (CT) and endoscopy confirmed a mid-esophageal perforation despite initial suspicion of a muscle sprain. Notably, symptom onset followed a forceful pulling maneuver on a bedside rail to sit up, an exertional Valsalva-like strain that can acutely increase intra-esophageal pressure and is a plausible precipitant of Boerhaave syndrome. The patient died 21 days later after a do not resuscitate (DNR) order was signed. We report this uncommon case and discuss the diagnostic challenges. CONCLUSIONS This case emphasizes the importance of promptly identifying esophageal perforation in patients with vague symptoms. Early imaging and intervention are essential, and Boerhaave syndrome should be suspected when unexplained shoulder or chest pain coexists with Hamman's sign or cervical subcutaneous emphysema.