Boerhaave’s syndrome as an initial presentation of eosinophilic esophagitis: a case series
A 43-year-old Caucasian male with history of intermittent solid food dysphagia presented to emergency room with sudden onset nausea, vomiting, and intense epigastric pain. Thirteen years prior to presentation patient had a spontaneous esophageal rupture for which he underwent left thoracotomy and primary repair complicated by prolonged leakage of the esophagus requiring chest tube drainage. Work up at that time identified no obvious etiology.\nOn this presentation, CT scan revealed mediastinal air below the level of the carina compatible with rupture of the distal esophagus (). Water soluble contrast swallow demonstrated extravasation of contrast at the right aspect of the distal esophagus just above a narrowing with evidence of contrast draining above and below the diaphragm as well as air tracking into the mediastinum (). The patient underwent esophageal resection, cervical esophagostomy and jejunostomy. Intra-operative esophagoscopy revealed a ringed or feline appearance to the esophagus and a 1-cm rupture just proximal to the gastroesophageal junction. Full thickness resection specimen revealed increased transmural eosinophilia with multiple fields demonstrating >25 eosinophils/hpf and up to 55 eosinophils/hpf, consistent with EoE ( and insert).\nPostoperatively, the patient was treated with 40 mg of prednisone tapered over 30 days. Six months later, he underwent completion esophagectomy with gastric pull-up. Surgical specimen at that time showed no evidence of eosinophilia (), suggesting improvement following systemic corticosteroid therapy. Surgical anastamosis was uncomplicated.