Boerhaave Syndrome With Concomitant Duodenal Perforation: A Rare Case Complicated by Mediastinitis and Empyema.

Boerhaave syndrome (spontaneous esophageal rupture) remains a surgical emergency with high mortality, particularly when complicated by mediastinitis, pleural empyema, and septic shock. Concomitant intra-abdominal perforation significantly increases morbidity. We report a case of a 61-year-old male patient presenting with hemodynamic instability due to distal esophageal rupture and duodenal perforation. Imaging revealed bilateral pneumothorax, pneumomediastinum, pneumoperitoneum, and extensive pleural effusions. The patient underwent emergent exploratory laparotomy with esophageal repair over T-tube placement, mediastinal lavage, primary duodenal repair, bilateral chest tube placement, decompressive gastrostomy, and feeding jejunostomy. The postoperative course was complicated by septic shock, bilateral pleural empyema requiring re-interventions including thoracotomy and pleurodesis, multidrug-resistant pulmonary infections, axillary vein thrombosis, Clostridioides difficile colitis, and prolonged mechanical ventilation. After comprehensive multidisciplinary management in the ICU, gradual respiratory and hemodynamic stabilization was achieved.