CRA49 A DIAGNOSIS CONUNDRUM; BILATERAL EMPYEMA AS AN ATYPICAL PRESENTATION OF BOERHAAVE SYNDROME

Heamah Krishnan

Sarawak General Hospital

Background
Boerhaave syndrome, a rare condition characterised by sudden perforation of the oesophagus This case presents a young patient with Boerhaave’s complicated by mediastinitis and bilateral empyema rupture due to increased intraluminal pressure, which often presents with diagnostic delays. We report a unique case complicated with bilateral empyema.

Case Presentation
A 30-year-old male presented with shortness of breathing for the past 2 days prior to admission and fever. Initially, he was mildly tachycardic and hypoxic. The initial chest X-ray shows left hydropneumothorax and pneumomediastinum. Cytochemical analysis of the pleural fluid was consistent with empyema. The patient developed progressive respiratory failure requiring NIV and transfer to the intensive care unit (ICU), where he was treated with wide-spectrum antibiotics and second chest tube on right was inserted. Bilateral chest tubes drained purulent material; cultures grew Klebsiella pneumonia. Further history after a few days of admission revealed that the patient had excessive alcohol consumption and then developed persistent vomiting prior to admission. Urgent OGDS was done by the upper GI team, revealing an oesophageal fistula 2 cm above GOJ, which subsequently proceeded with ENET insertion.  CT Thorax shows an oesophageal fistula with bilateral empyema. The patient progress was favourable, enteral nutrition was well tolerated, and there were no signs of respiratory failure. Chest drains were able to be turned off, and the patient was discharged well with further follow-up.

Conclusion
Here we would like to highlight diagnostic challenges. This case points out the need for high clinical suspicion for Boerhaave syndrome, even with atypical presentations, and the importance of aggressive multidisciplinary management in improving outcomes for severe complications like bilateral empyema.