Boerhaave Syndrome in the Intensive Care Unit: A Diagnostic Challenge.

Spontaneous esophageal rupture (Boerhaave syndrome) is a rare and life-threatening condition associated with high morbidity and mortality, particularly when diagnosis and source control are delayed. We report the case of a 73-year-old man presenting with vomiting, chest pain, and dyspnea. Computed tomography revealed extensive pneumomediastinum, and endoscopy confirmed a distal esophageal perforation with mediastinopleural contamination. The patient developed septic shock requiring intensive care support, including mechanical ventilation and vasopressors. Endoscopic vacuum therapy (EVT) was initially attempted but failed to achieve adequate source control, leading to thoracotomy, pleural debridement, T-tube placement, gastrostomy, and feeding jejunostomy. Pleural cultures grew Enterococcus faecalis and Candida krusei, prompting escalation of antimicrobial therapy. Despite a prolonged intensive care unit stay and multiple interventions, the patient progressively improved and was discharged for continued recovery. This case highlights the importance of early recognition, multidisciplinary management, and timely escalation from endoscopic to surgical treatment in complex Boerhaave syndrome.