Esophageal perforation mimicking an acute inferior myocardial infarction: a case report

Background: Esophageal perforation is a rare but life-threatening condition associated with a high mortality rate and often presents with nonspecific clinical manifestations that can lead to delayed diagnosis and treatment. When combined with ST-segment elevation on electrocardiography (ECG), it can be particularly challenging to distinguish esophageal perforation from acute inferior myocardial infarction, as the two conditions may share similar ECG findings. Case Description: We report the case of a 65-year-old man with a significant history of long-term alcohol consumption who presented to our hospital (the Affiliated Hospital of Liaoning University of Traditional Chinese Medicine) with persistent oppressive pain in the anterior and posterior left chest. Initially, the patient was diagnosed with acute coronary syndrome based on the ECG findings, which showed Q-wave and ST-segment elevation in the inferior leads. However, further dynamic monitoring of myocardial necrosis markers, including myoglobin and troponin I, yielded negative results inconsistent with acute myocardial infarction. Subsequent enhanced computed tomography revealed thickening and discontinuity of the wall of the thoracic esophagus with an irregular, mixed-density shadowing of the surrounding soft tissue confirming the diagnosis of esophageal rupture. Despite prompt recognition and transfer to a hospital with surgical capabilities, the patient tragically succumbed to esophageal rupture and hemorrhage while awaiting surgery. Conclusions: This case highlights the importance of maintaining a broad differential, including esophageal rupture, in patients exhibiting necrotic Q waves and ST-segment elevation in the inferior wall of the ECG, especially in the absence of reciprocal changes in the lateral leads and the lack of abnormal markers of myocardial necrosis. Prompt recognition of this rare but potentially fatal condition is crucial for initiating appropriate treatment and improving patient outcomes. Emergency physicians should be aware of this atypical presentation of esophageal perforation mimicking an acute myocardial infarction and consider this differential diagnosis when faced with discordant clinical and diagnostic findings.