Unusual case of retrosternal chest pain: a twist in the tale

Background

Oesophageal perforation is a rare and potentially life-threatening condition with a 20% survival rate. There are several causes of which common among them is being iatrogenic, spontaneous, or by trauma, tumours or foreign bodies (FBs). FBs account for 9%–35% of all oesophageal perforations.1 Unintentional ingestion of FBs is more common in children than adults. In adults, accidentally ingested FBs are often swallowed spontaneously with the passage of food without any complications. Most commonly involved FBs in adults are dental prosthesis, meat or fish bones.1 Abdominal pain is a common presentation in thoracic oesophageal FB perforation. Making a diagnosis in thoracic oesophageal perforation is difficult as perforation can get sealed off and remain indolent for a long time, or the symptoms can mimic other disorders and often leads to delayed diagnosis and management, seen in >60% of cases.2 Endoscopy remains a successful diagnostic and therapeutic method enabling the extraction of the FB.3 We report a case where an atypical FB (a piece of coconut shell) presented in an atypical manner as retrosternal chest pain and respiratory distress. Radiological tests including oral contrast CT did not show any obvious perforation or FB. Owing to delayed diagnosis, the patient already had fatal complications. However, multidisciplinary teamwork through various specialities played an integral part in achieving safe and effective patient care.4 5

Case presentation

A 62-year-old previously healthy man was referred to our emergency department with sudden onset, progressive retrosternal chest pain and decreased appetite since 4 days, associated with sweating and breathlessness that progressed to severe respiratory distress over the last 2 days.

He had no antecedent history of marked vomiting, dysphagia or odynophagia and denied any FB sensation/ingestion. Bowel and bladder habits were regular. He had no significant medical history.

At admission, he was afebrile with a heart rate of 100 beats/min, blood pressure of 120/70 mm Hg, respiratory rate of 35 breaths/min, oxygen saturation of 97% with 60% fractional inspired oxygen through venturi mask. He was alert and oriented but appeared uncomfortable on the stretcher. Physical examination revealed reduced air entry on the right side with bilateral basal crepitations. Intercostal drainage (ICD) tube in situ on the right side with purulent discharge of nearly 40 mL. The abdomen was soft on palpation with tenderness and guarding in the right hypochondrium. The rest of the physical examination was unremarkable.

Investigations

Routine blood tests showed a normal haemoglobin and platelet count (154 g/L and 179×10⁹/ L, respectively), a leucocytosis (White blood Cell Count (WCC) 10.4×10⁹/ L) predominantly neutrophilic (66%) with left shift and toxic granules and an elevated C-reactive protein (CRP) (>350 mg/L). Blood culture showed growth of coagulase-negative staphylococcus. Other blood investigations were unremarkable. The patient’s chest radiograph, on admission, did not show any evidence of perforation or FB (figure 1). Additionally, the ECG showed no signs of myocardial infarction (figure 2). ECG and coronary angiogram reports were normal. Contrast-enhanced CT of thorax and abdomen showed right hydropneumothorax with pneumomediastinum (figure 3), left mild pleural effusion with bilateral collapse-consolidation of underlying lungs, with no oral contrast leakage through upper gastrointestinal (GI) tract (figure 4).

Upper GI endoscopy showed an FB (piece of coconut shell) lodged at the lower oesophagus, almost 22 cm from upper incisor teeth penetrating the mucosa without any evidence of perforation (figure 5). Microscopy and culture of pleural fluid aspirate (figure 6) showed growth of Peptoniphilus asaccharolyticus. It is a gram-positive obligate anaerobic coccus bacteria, a common gut commensal that further suggest the presence of a sealed oesophageal perforation.

Thus, endoscopy and contrast-enhanced CT thorax and abdomen established the diagnosis of right hydropneumothorax, left mild pleural effusion and pneumomediastinum secondary to closed oesophageal perforation due to an FB.

Differential diagnosis

Intense retrosternal pain in an elderly male requires prompt evaluation of cardiovascular diseases, namely acute coronary syndrome, aortic dissection and pulmonary embolism. Normal coronary angiography excluded the diagnosis of the acute coronary syndrome and aortic dissection. The normal D-dimer weakened the likelihood of a pulmonary embolism. Cardiac tamponade, pneumonia, tension pneumothorax were the other important differential diagnosis as the patient had severe respiratory distress, but all of them had been excluded through normal ECG and chest X-ray findings. The idiopathic oesophageal rupture, Boerhaave syndrome, is another rare differential.

Treatment

On arrival to the emergency department, he had right ICD tube in the sixth intercostal space, inserted from the referred hospital because of pyothorax. The ICD tube had repositioned to fourth intercostal space due to lack of water column movement in underwater seal. He was intubated because of respiratory distress. We initiated antibiotic treatment with linezolid and clindamycin as blood culture, and ICD was growing coagulase-negative streptococcus and P. asaccharolyticus, respectively. Tramadol was initiated to control the intense lower thoracic pain. As there was no clinical improvement, an upper GI endoscopy was done that revealed an FB (piece of coconut shell measuring 2 cm). It was removed with a flexible endoscope using grasping forceps. He was later shifted to the critical care unit. The patient remained to fast and was treated with total parenteral nutrition (TPN), and antibiotics were continued. Owing to persistent collection in the right pleural space, a new pigtail catheter was inserted. The results of an oesophagogram 10 days later showed no leak. Oral ingestion was resumed, and the pleural drain was removed. The patient recovered over 4 weeks following extensive care through multidisciplinary teamwork between critical care unit and surgeons. He returned home in stable condition.

Outcome and follow-up

Owing to extensive multidisciplinary approach through various departments, even though the patient had fatal complications due to delayed diagnosis, he had a favourable recovery period. After 4 months, the patient was able to resume his daily activities and was on regular follow-up.