Acute phlegmonous esophagitis presenting as chest pain: A case report.

RATIONALE: Acute phlegmonous esophagitis (APE) is bacterial infection of the submucosal and muscularis layers of the esophagus. APE is a rare but life-threatening disease, and few studies have reported it. PATIENT CONCERNS: A 63-year-old Korean woman was admitted to the emergency department complaining of chest pain. Contrast-enhanced computed tomography revealed diffuse esophageal wall thickening with low attenuation and paraesophageal fluid collection in the mediastinum. Esophagomyotomy, mediastinal abscess drainage with a right thoracotomy, and left 3-port video-assisted thoracoscopy were performed in the operating room. DIAGNOSES: Contrast-enhanced computed tomography revealed diffuse esophageal wall thickening with low attenuation and paraesophageal fluid collection in the mediastinum. INTERVENTIONS: Esophagomyotomy, mediastinal abscess drainage with a right thoracotomy, and left 3-port video-assisted thoracoscopy were performed in the operating room. OUTCOMES: The patient followed up through an outpatient visit 4 days later discharged. The patient progress was good, and she decided to visit the patient if she had pain afterwards. LESSONS: As APE is rare but deadly, strategies to identify APE in patients with chest pain or dysphagia are needed in emergency department.

Descending necrotizing mediastinitis caused by Streptococcus constellatus: A case report and review of the literature.

RATIONALE: Descending necrotizing mediastinitis (DNM) is a rare but severe mediastinal infection. If not diagnosed and treated promptly, the consequences can be very serious. Here, we shared a successful diagnosis and treatment case of DNM that originates from oral to neck and mediastinum caused by Streptococcus constellatus (S constellatus). S constellatus is a clinically uncommon gram-positive coccus and is known for its ability to form abscesses. Timely surgical drainage and the correct use of antibiotics are key to successful treatment. PATIENT CONCERNS: A 53-year-old male admitted to hospital with painful swelling of the right cheek, persistent oral pus and moderate fever lasting 1 week, followed by rapid development of a mediastinal abscess. DIAGNOSES: He was diagnosed with DNM caused by S constellatus. INTERVENTIONS: On the evening of admission, an emergency tracheotomy and thoracoscopic exploration and drainage of the right mediastinum, floor of the mouth, parapharynx and neck abscess were performed. Antibiotics were administered immediately. OUTCOMES: At 28 days post-operatively, the abscess was absorbed, bilateral lung exudate decreased and the patient temperature, aspartate transaminase, alanine transaminase, bilirubin and platelets returned to normal. The patient was discharged after completing 4 weeks of antibiotic therapy. Follow-up at 3 months after discharge revealed no recurrence of the abscess. LESSONS: Early surgical drainage and antibiotics treatment are important in mediastinal abscesses and infectious shock due to Streptococcus asteroids.

Large Thoracic Lymphadenopathy and Pulmonary Nodules in Young Man.

CASE PRESENTATION: A 33-year-old man with obesity, systemic arterial hypertension, and psoriasis who had been treated previously with little success by a pulmonologist for chronic unproductive irritant cough came to the outpatient pulmonary department because of profuse cough and short syncope (probably cough-induced). Chest radiography revealed widened mediastinum with lobular, polycyclic contours that was suspected to be a large mediastinal lymphadenopathy or mediastinal mass.

Ectopic Anterior Mediastinal Pancreas: An Unusual Case of New Onset Hemoptysis.

Ectopic pancreas within the anterior mediastinum is a rare congenital anomaly. We present a case of a solid anterior mediastinal mass that presented with hemoptysis and ground glass parenchymal changes in the right upper lobe. Robotic surgical resection was completed, and final pathology was consistent with benign pancreatic tissue. The patient fully recovered with no recurrence of hemoptysis. Ectopic pancreas, although uncommon, should be included in the differential for solid and cystic anterior mediastinal masses; surgical resection is often curative and effectively manages symptoms.

Cyanoacrylate injection treatment for postoperative leakage of Boerhaave's syndrome: A case report.

RATIONALE: Surgical treatment remains the most effective option for treating Boerhaave's syndrome. However, in cases of postoperative anastomotic leakage of Boerhaave's syndrome, endoscopic interventions such as over-the-scope clip, stenting, or cyanoacrylate injection have emerged over reoperation. PATIENT CONCERNS: We report the case of a 50-year-old male patient who presented with vomiting and abdominal pain after alcohol consumption. Laparoscopic surgery was performed for primary closure of a laceration at the lower esophagus, and for the closure of a Boerhaave's syndrome, which was detected by abdominal computed tomography. However, postoperative anastomotic leakage was confirmed through esophagography after the operation. In our case, endoscopic treatment with an over-the-scope clip and stenting were not effective for the repair of the anastomotic leakage, but cyanoacrylate injection successfully healed the anastomotic leakage. DIAGNOSES: Boerhaave's syndrome was initially detected by abdominal computed tomography, but postoperative anastomotic leakage after the operation was confirmed with esophagography. INTERVENTIONS: A total of 2.0 cc of N-butyl-2-cyanoacrylate and lipiodol mixture (at 1:1) was injected into the leakage tract through the perforation entrance. OUTCOMES: Complete healing of the anastomotic leakage was confirmed with a follow-up esophagoscopy. LESSONS: N-butyl-2-cyanocrylate injection treatment can be used as a rescue option for postoperative leakage when over-the-scope clips and stenting fail for this indication.

Boerhaave syndrome with double esophageal perforation. About a case.

INTRODUCTION: Boerhaave syndrome consists of a spontaneous perforation of the esophagus, with high mortality. OBJECTIVE: To describe a case with Boerhaave syndrome with double esophageal perforation. CASE REPORT: 33-year-old female who came to the hospital for emetic symptoms, followed by retrosternal chest pain; chest drainage is performed. Esophageal perforation was diagnosed late and he was transferred to a tertiary level institution. Successive treatments were performed: videothoracoscopy and pleural decortication; alimentary jejunostomy; esophageal stent placement, diagnosis of new perforation, pyloric exclusion, new stent placement, and esophageal exclusion. CONCLUSIONS: The delay in diagnosis contributed to the fatal outcome of the patient.

INTRODUCCIÓN: El síndrome de Boerhaave consiste en una perforación espontánea del esófago, con alta mortalidad. OBJETIVO: Describir un caso de síndrome de Boerhaave con doble perforación esofágica. CASO CLÍNICO: Mujer de 33 años que acude al hospital por un cuadro emético, seguido de dolor torácico retroesternal; se realiza drenaje torácico. Se diagnostica tardíamente perforación esofágica y se traslada a una institución de nivel terciario. Se realizaron sucesivos tratamientos: videotoracoscopia y decorticación pleural, yeyunostomía alimentaria, colocación de endoprótesis esofágica, diagnóstico de nueva perforación, exclusión pilórica, colocación de nueva endoprótesis y exclusión esofágica. CONCLUSIONES: El retardo en el diagnóstico contribuyó al desenlace fatal de la paciente.

Clinical features of idiopathic esophageal perforation compared with typical post-emetic type: a newly proposed subtype in Boerhaave's syndrome.

BACKGROUND: n our previous nationwide survey report on esophageal perforation, we proposed the existence of cases with idiopathic esophageal perforation at a certain rate. AIMS: To elucidate the clinical characteristics of idiopathic esophageal perforation, we performed a comparative analysis between cases with idiopathic type and post-emetic type esophageal perforation. METHODS: This study enrolled 139 patients with esophageal perforation (post-emetic type: idiopathic type = 115:24) as the subjects of nationwide survey on esophageal perforation. We conducted detailed studies on chief complaints, inflammatory responses, initial diagnosis, location and situation of the perforation site, time to therapeutic intervention, and prognosis between the two groups. RESULTS: Compared with post-emetic type, cases of idiopathic type tended to exhibit rear-side perforation (p = 0.052) and significantly less presented chest pain (p = 0.002). Consequently, cases of idiopathic type significantly missed to diagnose as esophageal perforation compared with post-emetic type (p = 0.042). With regard to inflammatory response, cases of post-emetic type experienced hyperthermia compared with idiopathic type (p = 0.033). On the other hand, cases of idiopathic type exhibited significantly higher level of C-reactive protein than post-emetic type (p = 0.004). In addition, it took longer time until starting treatment in the cases of idiopathic type (p < 0.0001) and the cases of idiopathic type showed significantly worse prognosis than the cases of post-emetic type (p = 0.009). CONCLUSION: This study first focused on the characteristics of idiopathic esophageal perforation that have been included in so-called Boerhaave's syndrome. The pathophysiology of the idiopathic type should be separately understood from post-emetic type, because the diagnostic and prognostic features largely differ.

Suspecting a fatal condition on a plain chest radiograph; Boerhaave syndrome.

Spontaneous oesophagus rupture, also known as Boerhaave syndrome, is a rare but near-fatal medical condition and despite recent medical advancements, it remains a diagnostic challenge for front-door clinicians. The authors describe a similar presentation in an elderly gentleman who presented to the emergency department with sudden chest pain post vomiting. His initial chest radiograph showed bilateral dense consolidations and pleural effusions, and was treated as sepsis secondary to bilateral pneumonia. He underwent computed tomography pulmonary angiogram to rule out pulmonary embolism because of his chest pain with elevated D-dimer which confirmed the diagnosis of oesophagus rupture. His care was transferred to Surgical and Intensive care colleagues with plans for radiological chest drain insertion to limit contamination of mediastinum, however the patient became hypoxic and hypotensive and despite maximal organ support passed away within 6 hours of admission. Retrospect review of chest radiograph revealed Peri-oesophageal air tracking, a sign of Boerhaave syndrome. The aim of this case is to emphasise the importance of raising the suspicion of Boerhaave syndrome in patients with sudden chest pain, unexplained pleural effusion or pneumothorax with a history of recent vomiting as early diagnosis holds the key to prompt lifesaving management.

Right-Sided Cardiac Calcifying Fibrous Pseudotumor Manifesting With Embolic Stroke.

This report describes the case of a 43-year-old woman with a right-sided cardiac calcifying fibrous pseudotumor who presented with embolic stroke. This rare clinicopathologic entity should be included in the differential diagnosis of cardiac masses. Tissue diagnosis should be pursued. Management should be tailored to symptoms and feasibility of resection.

Extrapericardial Tamponade After Blunt Trauma.

Cardiac tamponade results from compression of the heart and great vessels. Mediastinal hematoma has been reported in association with cardiac tamponade in multiple settings, including nonaortic mediastinal hemorrhage from cervical spine fractures, aortic and carotid aneurysmal rupture, mediastinal penetrating trauma, and cardiac penetrating trauma. A few cases of blunt trauma to the anterior chest wall resulting in tamponade formation have been reported. We present a patient with an anterior mediastinal hematoma resulting from blunt chest trauma that caused extrapericardial cardiac tamponade due to bleeding from a branch of the left internal mammary artery after a motor vehicle collision.

Hydatid Disease With Pseudoaneurysm Formation of the Descending Thoracic Aorta.

Human Echinococcus disease is a zoonosis that primarily affects the liver and lungs. We report a rare case of hydatid disease in the posterior mediastinum with pseudoaneurysm formation of the descending thoracic aorta and erosion of thoracic vertebral bodies. The patient was surgically treated with removal of multiple daughter cysts and primary repair of the aorta.

Mediastinal fluid as a predictor for esophageal perforation as the cause of pneumomediastinum.

PURPOSE: Pneumomediastinum is not an uncommon finding on emergency CTs and is seen in a variety of settings, including acute trauma, recent repeated emesis and recent thoracic surgery, and after EGD (Kouritas et al. J Thorac Dis 7(Suppl 1):S44-S49, 2015). The purpose of this study was to examine cases of CT pneumomediastinum for distinguishing features which could support or exclude esophageal injury as a cause, which in turn could help guide evaluation of these patients. METHODS: CT chest scans showing pneumomediastinum performed in the emergency department between January 2013 and December 2018 were included. The presence or absence of fluid within the mediastinal compartments was correlated with esophageal perforation and subdivided into the clinical scenarios of trauma, suspected Boerhaave's syndrome, recent surgery or EGD, and other. Accuracy of this finding was compared with fluoroscopic esophagography. RESULTS: Twenty-two cases of esophageal perforation were identified out of a total of 324 included cases. The cases were subdivided into four categories: trauma, suspected Boerhaave syndrome, suspected iatrogenic perforation from recent procedure or surgery, and other. Two hundred fourteen cases of pneumomediastinum occurred in the setting of trauma, and 2 had esophageal perforation. Both showed mediastinal fluid. Twenty-two cases had mediastinal fluid without perforation. Seventeen cases of pneumomediastinum occurred in the setting of suspected Boerhaaves, and 3 had esophageal perforation. Every case with esophageal perforation had mediastinal fluid, and every case without perforation had no mediastinal fluid. Nine cases of pneumomediastinum occurred in the setting of suspected iatrogenic perforation after recent surgery or procedure. Six cases had esophageal perforation, and 5 of these had mediastinal fluid. All three cases without perforation also had mediastinal fluid. Eighty-six cases were classified as other and included a variety of clinical histories. This category contained 8 esophageal perforations, 7 of which had mediastinal fluid. One case of mediastinal fluid was not associated with esophageal perforation in this category. CONCLUSION: The presence of mediastinal fluid, specifically within the visceral compartment, strongly suggests esophageal injury, and its absence strongly argues against it. An important caveat is in the setting of recent surgery, in which mediastinal fluid can be seen normally. An esophagography study can supplement the evaluation if there is a discrepancy between the clinical suspicion and the original CT findings.

Proposed characterization of the syndrome of epidural pneumatosis (pneumorrhachis) in patients with forceful vomiting from diabetic ketoacidosis as a clinico-radiologic pentad based on systematic literature review & an illustrative case report.

BACKGROUND: Previous literature on epidural pneumatosis (pneumorrhachis, or air in epidural cavity) associated with forceful vomiting in a patient with diabetic ketoacidosis (DKA) has consisted of individual case reports without comprehensive syndrome characterization due to syndromic rarity, with the largest previous literature review comprising 6 cases. Presumed pathophysiology is air escaping from alveolar rupture from forceful vomiting via tissue planes to cause epidural pneumatosis. AIM: Systematically review literature to facilitate syndromic diagnosis, evaluation, and treatment. A new illustrative case is reported. METHODS: Systematic review of literature using 2 independent readers, 2 computerized databases, and the following medical terms/keywords: ["epidural pneumatosis" OR "pneumorrhachis"] AND ["diabetes" OR "diabetic ketoacidosis" or "DKA"]. Discrepancies between 2 readers were resolved by consensus using prospectively developed study inclusion criteria. Two readers independently abstracted case report. Prospective review protocol and patients, problems, intervene, comparison group, outcomes discussed in Methods section of paper. RESULTS-SYSTEMATIC-LITERATURE-REVIEW: Revealed 10 previously reported cases plus 1 new case (see below) that shows this syndrome presents rather stereotypically with the tentatively proposed following pentad (% of patients fulfilling individual criterion): 1-forceful vomiting (100%), 2-during DKA (100%), 3-pneumomediastinum from forceful alveolar rupture (100%), 4-epidural pneumatosis from air escape from pneumomediastinum (100%), and 5-no complications of Boerhaave syndrome or of focal neurological deficits (100%). Pentad is pathophysiologically reasonable because forceful vomiting can cause alveolar rupture, pneumomediastinum, and air entry into epidural space. RESULTS-ILLUSTRATIVE-CASE-REPORT: Epidural pneumatosis occurred in a 33-year-old-male with poorly controlled diabetes mellitus type 1 who presented with forceful vomiting while in DKA. Radiologic findings also included subcutaneous emphysema, pneumomediastinum, and small pneumothorax. The patient rapidly improved while receiving acute therapy for DKA, and was discharged after 2 hospital days. STUDY LIMITATIONS: Limited number of analyzed, retrospectively reported cases. Case reports subject to reporting bias. Specificity, positive predictive value, and negative predictive value not meaningfully analyzed in this homogeneous population. CONCLUSIONS: Based on systematic review, syndrome is tentatively proposed as a pentad with: 1-forceful vomiting, 2-during DKA, 3- pneumomediastinum, 4-epidural pneumatosis, and 5-no complications of Boerhaave syndrome or focal neurological deficits. Proposed pentad should be prospectively tested in a larger population including patients with this versus closely related syndromes.