Abstract

Case Description: We present a 69-year-old Caucasian male with a past medical history of COPD, severe coronary artery disease with stent placement, severe aortic stenosis, heart failure with preserved ejection fraction, stroke, and hypertension who presented to the emergency department with substernal chest pain and worsening shortness of breath for three days. He had associated orthopnea and paroxysmal nocturnal dyspnea. Of note, the patient was recently discharged from the hospital status post left axilla abscess debridement. He was discharged on oral doxycycline for 7 days. Initial laboratory values showed mildly elevated troponin. Vital signs were significant for mild hypertension. Chest x-ray on admission showed new-onset small to moderate bilateral pleural effusion and mild pulmonary vascular congestion in comparison to chest x-ray on previous admission. Heart failure and pneumonia protocols were initiated and the patient was admitted to the PCU. Cardiology was consulted and after evaluation of the patient, recommended cardiac catheterization to rule out obstructive CAD.  After a few days, the patient developed worsening respiratory distress, was placed on BiPAP, and transferred to the ICU. While in the ICU, the patient developed increased work of breathing and was subsequently intubated. Post-intubation, CXR to confirm the endotracheal tube position revealed a right hydropneumothorax. A chest tube was placed and two liters of brown, purulent fluid was drained.  The patient’s respiratory status improved and he was extubated the next day.  Cardiothoracic surgery placed a surgical chest tube to assist with drainage of the pleural fluid. The patient complained daily of right shoulder pain and diminished appetite.  Aside from these complaints, he improved over the next few days, but his chest tube continued to drain between 2-6 L daily. The pleural fluid was sent for culture and yielded positive growth for Candida albicans and glabrata. He began an extended course of IV antifungal medication.  Five days later, the patient became delirious and exhibited signs of septic shock.  His condition rapidly deteriorated leading to intubation and pressors for support. His chest tube continued to drain dark brown fluid. On further questioning, the patient’s wife noted the patient had episodes of vomiting prior to developing the shortness of breath that led to hospitalization. An esophageal tear was suspected and a gastrografin swallow study confirmed the suspicion.  Endoscopic esophageal stent placement was done.  Patient was weaned off sedation a few days later and was able to communicate with physicians. The decision was made to admit the patient to hospice, and he was discharged. 

Discussion: One known side effect of oral doxycycline, which this patient was taking, is GI upset. Retching and vomiting can lead to Boerhaave syndrome, a spontaneous cause of esophageal rupture. It is essential to have an index of suspicion for esophageal perforation in patients complaining of shortness of breath and recent vomiting, especially in the context of a fungal empyema.  Fungal empyema is exceedingly rare and of those identified to be Candida, a common source is the GI tract. If not identified within the first 24 hours, the survival rate of an esophageal tear decreases greatly due to mediastinal infection. This case illustrates a rare case of Candida empyema caused by Boerhaave syndrome secondary to oral doxycycline ingestion.