while classically described as a post - emetic distal esophageal rupture just proximal to the gastroesophageal junction , presenting with chest pain , pneumomediastinum and a left - sided pleural effusion , the actual presentation is oftentimes nonspecific , mimicking many other clinical disorders and resulting in a delay in diagnosis and therapeutic intervention . case reports of boerhaave 's syndrome presenting as mid - esophageal perforation associated with a right - sided pleural effusion are particularly uncommon [ 17 ] . an 86-year - old female presented to the emergency department with complaints of chest pain and dyspnea after gagging while swallowing a pill . she described the pain as sharp in nature , radiating to her neck , back and epigastrium . she was noted to be anxious ; breath sounds were present bilaterally but diminished at the bases , and she had tenderness in the upper abdomen . she was intubated for persistent respiratory distress and transferred to our hospital for further care . on arrival , she was hemodynamically normal . pertinent laboratory markers included a white blood cell count of 11 , serum bicarbonate of 20 and a lactate of 1.5 . a computed tomography ( ct ) scan of the chest with oral contrast , administered immediately before the study , demonstrated extravasation from the middle third of the esophagus into the right chest and mediastinum with minimal flow distally into the lower esophagus and stomach ( fig .  1 ) . the clinical picture was suggestive of a distal esophageal obstruction from either stricture or neoplasm . bilateral chest tubes were placed and supportive care initiated , including broad - spectrum antibiotics and fluconazole . an urgent esophagogastroduodenoscopy ( egd ) was performed to evaluate for mass or stricture in the distal esophagus , and this showed an obvious perforation with extrusion of fluid and gastric contents noted along the right mid - esophagus with no evidence of stricture or tumor ( fig .  2 ) . the patient was taken to the operating room , and a right posterolateral thoracotomy was performed . upon entering the chest , murky purulent fluid was noted throughout the right pleural space and mediastinum . further exploration revealed a transmural perforation in the mid - esophagus , originating at the level of the azygos vein , extending 5 cm distally . the right pleural space was debrided and irrigated , and the esophageal tear was repaired primarily after it had been fully exposed . 3 - 0 vicryl sutures were placed in an interrupted fashion through the mucosa for the full length of the repair , and this was reinforced with an intercostal muscle flap as the muscular layer of the esophagus was not suitable for repair sutures . figure  1:ct demonstrating extravasation of oral contrast into the right chest and mediastinum . figure  2:esophagogastroduodenoscopy confirming site of perforation along the right lateral wall of the mid - esophagus . esophagogastroduodenoscopy confirming site of perforation along the right lateral wall of the mid - esophagus . an esophagram obtained on postoperative day 9 demonstrated no sign of esophageal leak , and she was then started on an oral liquid diet that was advanced to soft foods . she was discharged on postoperative day 17 . at follow - up approximately 1 month after surgery , she remained in good health . first , imperative to our patient 's good outcome was that the connection between a right - sided pleural effusion and an associated esophageal pathology was immediately recognized . many of the previously published case reports of boerhaave 's syndrome presenting as a right - sided pleural effusion focus on a delay in diagnosis as a significant contributing factor to persistently high mortality rates [ 15 ] . indeed , mortality rates > 56% after 24 h and 7589% after 48 h have been reported [ 810 ] . in an effort to identify a single salient feature that might clinch the diagnosis , an upright chest x - ray was consistently listed as the most important initial test [ 1 , 2 , 4 , 5 ] . it is clear , however , that simply obtaining the appropriate diagnostic tool is not enough . in this case , suspicion for esophageal perforation , in conjunction with the history and radiographic findings , resulted in a quick transfer to our hospital center , where definitive surgical management took place in < 24 h. when presented with a perforation of the mid - esophagus , it is important to evaluate for intrinsic disease of the esophagus , as this will impact both clinical presentation and surgical intervention . distal obstruction from an esophageal tumor would require esophagogastrectomy , whereas perforation of an otherwise healthy esophagus would be amendable to primary or reinforced repair . this was quickly realized in our case , yet it still remains unclear why our patient 's site of rupture was unusual . other possible causes could have included a peptic stricture , a paraesophageal hernia with obstruction or an underlying dysmotility ; none of which were appreciated during our patient 's endoscopic exam . the majority of previously reported cases were post - emetic ruptures associated with gastroesophageal reflux and barrett 's esophagus lesions ; one was associated with a bleeding duodenal ulcer and another with a hiatal hernia [ 15 ] . none of these findings , however , would intuitively explain a mid - esophageal perforation . it also underscores the importance of a meticulous diagnostic and therapeutic approach to the management of an often elusive and difficult disease process .
there are few published case reports of boerhaave 's syndrome presenting as a mid - esophageal perforation associated with a right - sided pleural effusion . 
 we present an unusual case of spontaneous perforation of the mid - esophagus and discuss the surgical management and outcome . 
 our case underscores the importance of a meticulous diagnostic and therapeutic approach to the management of an often elusive and difficult disease process .