Esophageal Rupture Presenting with ST Segment Elevation and Junctional Rhythm Mimicking Acute Myocardial Infarction

Abstract

Esophageal rupture is a rare but potentially fatal cause of chest pain. The presentation is variable and can mimic other conditions such as aortic dissection, pulmonary embolism, and myocardial infarction (MI). A 71-year-old male with a history of coronary artery disease presented to the ED with complaints of acute chest pain and respiratory distress. Over the next 48 hours, the patient developed dynamic ST segment changes on surface electrocardiogram mimicking an inferolateral ST segment elevation MI accompanied by a junctional rhythm. Curiously, his cardiac enzymes remained negative during this time, but his clinical status continued to deteriorate. A subsequent CT scan demonstrated a lower esophageal rupture, and the patient underwent successful endoscopic stenting. While rare, prompt recognition of esophageal rupture is imperative to improving morbidity and mortality. While esophageal rupture has been noted to cause ST segment elevation before, this appears to be the first case associated with a junctional rhythm.

How electrically silent is the pericardium?

“…ST segment elevation has been reported in patients with acute cholecystitis, acute pancreatitis, perforated gastric ulcer and oesophageal rupture without evidence of acute myocardial infarction or inflammation 7 8. Thus, the current study shows that there is myocardial involvement in some of the patients with ST segment elevation.…”

Bilateral Empyema With Beta Hemolytic Group C Streptococcus and Streptococcus constellatus Co-infection Resulting From an Esophageal Perforation and Associated With Septic Shock, Diffuse ST Elevation, and New-Onset Atrial Fibrillation

“…The complications of esophageal perforation are caused by bacteria and digestive enzymes gaining direct access into the mediastinum, causing inflammation and leading to the development of potentially life-threatening mediastinitis, empyema, and sepsis [ 6 ]. Our patient had mediastinitis characterized by mediastinal fluid, atrial fibrillation, and pericarditis [ 9 , 14 ].…”

Boerhaave’s Syndrome Presenting in the Setting of Third-Degree Heart Block

“…There have been several cases of esophageal perforation presenting as an acute myocardial infarction or cardiac arrest, but cardiac arrhythmia has only been noted in 2 cases upon literature review. 9 , 16 This patient with third degree heart block, presenting with symptomatic bradyarrhythmia, would be a candidate for implanted permanent pacemaker (class I indication). However, the decision of when to place the pacemaker was complicated by his comorbidities and the presentation with sepsis.…”

“…The chest pain associated with esophageal rupture can often mimic aortic dissection, pulmonary embolism, and acute coronary syndrome, especially if the patient has other comorbidities predisposing them to coronary artery disease. 16 Cardiac complications of esophageal rupture are likely due to local inflammation secondary to leaking of gastric contents into the mediastinum. However, conduction abnormalities as a result of esophageal perforation have only been described twice in the literature and the mechanism of this complication is poorly understood.…”