Cytomorphology of Boerhaave's syndrome: A critical value in cytology
An 81-year-old female with a past medical history of hypertension, hypothyroidism, paroxysmal atrial fibrillation with rapid ventricular response, hyperlipidemia and chronic kidney disease presented with abdominal pain and vomiting after eating food. There were no complaints of chest pain, shortness of breath, cough or hemoptysis. Physical examination elicited pain scaled around 3-4/10 localized in the epigastric area. X-ray of the abdomen showed air-filled non-distended large and small bowel loops without impaction or obstruction. The initial clinical impression was gastroenteritis. A chest radiograph done on the following day of patient's presentation showed newly developed patchy areas of increased attenuation in the left lung base with an associated pleural effusion. A left sided chest tube was inserted and drained nearly 600 cc of gastrointestinal content-like fluid which was submitted for cytological and chemical examinations.\nThe pleural fluid analysis of this case showed lactate dehydrogenase of 3405 units/L, amylase of 5192 units/L (i.e., high), glucose 23 mg/dl (i.e., low) and pH of 7.0 (i.e., low). The white cell count was 4838/cumm and red blood cell count was 4000/cumm, supporting an exudative/inflammatory nature for this specimen and consistent with a diagnosis of ruptured esophagus.\nThe gross appearance of the specimen submitted for cytological examination showed thick, chunky, light brown, opaque fluid containing numerous pale tan and pale brown fragments. The cytological examination of the left pleural fluid revealed benign squamous cells, bacterial colonies, and fungal organisms consistent with candida, and vegetable material [Figures and ]; these combined features are most consistent with a ruptured esophagus. Spontaneous esophageal perforation is known as Boerhaave's syndrome. This is considered a CV for which the clinician has to be notified as soon as possible. The clinician was called immediately, and the patient underwent surgical esophageal repair of the esophageal rupture and left decortications of the pleura. The surgical specimen showed pieces of necrotic soft-tissue, bile, bacterial, and fungal colonies, vegetable material, and an acute inflammatory exudate [].