The case of a 72-Year-Old Male with Hematemesis and Pneumomediastinum due to Acute Bacterial Esophageal Necrosis

Abstract

Acute esophageal necrosis (AEN) is a relatively uncommon presentation of esophagitis. AEN is characterized by black necrotic esophageal tissue and is associated with high mortality rates. We discuss the case of a 72-year-old Caucasian male who was admitted to the medical intensive-care unit (MICU) for evaluation of pneumomediastinum. CT of the chest revealed a right lower lobe consolidation, pneumomediastinum, and marked thickening of the distal esophagus. Vital signs on arrival revealed a temperature of 38.3° Celsius, heart rate of 92 beats per minute, respiratory rate of 30 breaths per minute, blood pressure of 144/65, and oxygen saturation of 97% on 15 liters of supplemental oxygen via non-rebreather. Laboratory studies on arrival were remarkable for a white blood cell (WBC) count of 19.75 x109/L, procalcitonin of 3.53 ng/mL, and C-reactive protein (CRP) level 43.95 mg/dL. The patient was intubated for acute hypoxemic respiratory failure and started on intravenous (IV) pantoprazole as well as broad-spectrum antibiotics for possible pneumonia. Bedside bronchoscopy showed no obvious airway deformities or perforations on inspection but did reveal thick copious secretions that were sent for culture. Thoracic surgery was consulted, and an esophagogastroduodenoscopy (EGD) was performed, which demonstrated no obvious tear or perforation. However, it did show swollen and black mucosa primarily involving the distal esophagus. Tissue cultures from the EGD grew Klebsiella pneumoniae, which was also grown from the bronchial wash and bronchoalveolar lavage. EGD findings were consistent with AEN. Despite extensive supportive care, the patient ultimately expired. We propose that people with AEN who present with pneumomediastinum and those in whom AEN is found to be secondary to a bacterial cause require not only supportive measures but also prompt surgical consultation.