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A 46-year-old man presented to the emergency department having had 2 large, nonbloody vomits and abdominal pain over the preceding 3 hours. He had no history of gastresophageal reflux disease or other relevant medical conditions. He had a 20-year history of drinking 10-15 cans of beer a week. On examination, his abdomen was rigid and tender in the left upper quadrant. Laboratory results showed elevated leukocytes at 13.8 (normal 4.5-11.5) × 109/L with 77.8% neutrophils and high sensitivity C-reactive protein of < 0.02 (normal < 0.80) mg/dL. A chest radiograph showed pneumomediastinum, and a subsequent computed tomography scan of the patient's chest also showed pneumomediastinum and left hydropneumothorax. We diagnosed Boerhaave syndrome, perforation of the esophagus.

Xavier Valette and colleagues1 reported a high (66%) prevalence of mediastinal lymphadenopathy in 15 patients with COVID-19 admitted to their intensive care unit (ICU), an approximately 11-fold discrepancy with systematic reviews reporting pooled prevalence of 3·4%2 and 5·4%.3 This topic deserves further investigation, especially considering that small sample sizes imply large confidence intervals. Whereas our CT examinations were done at emergency department admission, Valette and colleagues' data1 derive from patients in the ICU. [...]our lower lymphadenopathy prevalence could be explained by the lower severity illness of our patients. After applying the Bonferroni correction for multiple comparisons to our series of patients (obtaining a p value threshold of 0·003, above which p values were not significant), we found no significant differences between patients with and without lymphadenopathies in terms of sex, age, history of cancer, non-invasive ventilation or ICU admission during hospitalisation, length of hospital stay, laboratory findings, and CT features such as parenchymal involvement and disease progression, both assessed according to the classification by Bernheim and colleagues4 (appendix).

Amebiasis, caused by Entamoeba histolytica, is an intestinal disease that can lead to severe complications such as ulcers and abscesses. While the intestine is most commonly affected, extraintestinal involvement is also possible. However, mediastinal amebiasis remains rare. This case report details a patient with amebiasis who developed an amebic mediastinal abscess, which subsequently ruptured into the pleural cavity, resulting in bilateral empyema and a pseudoaneurysm of the right subclavian artery. Treatment was promptly initiated with metronidazole, alongside closed pleural drainage. Additionally, endovascular stent placement was performed to address the right subclavian artery pseudoaneurysm. The patient was discharged in good health on the 37th postoperative day. The treatment approach described offers valuable clinical insights for frontline healthcare providers.

Boerhaave’s syndrome is a rare and life-threatening form of spontaneous esophageal perforation, typically triggered by forceful vomiting and often misdiagnosed due to nonspecific clinical features. Although Mackler’s triad (vomiting, chest pain, and subcutaneous emphysema) is classically associated with the condition, it is infrequently observed in full. We present the case of a 32-year-old man with a history of ulcerative colitis (UC) who presented to the emergency department with acute chest pain and repeated vomiting following dinner. He reported a sensation of food impaction and sought care 2 hours after symptom onset. Examination revealed subcutaneous emphysema and abdominal tenderness. Imaging with oral contrast-enhanced computed tomography revealed pneumomediastinum, pneumoperitoneum, and a distal esophageal perforation, confirming Boerhaave’s syndrome. He underwent robotic-assisted laparoscopic repair with anterior fundoplication, endoscopic stenting, and drainage. His postoperative course included thoracentesis, IV antibiotics, and a gradual reintroduction of diet. A mild UC flare was managed with mesalamine. He was discharged in stable condition on postoperative day 9 and had full radiologic recovery at 3 months. This case stands out for its complete presentation of Mackler’s triad, a rare occurrence that facilitated early diagnosis. The patient’s young age and concurrent UC added clinical complexity. Prompt imaging and early minimally invasive surgical management, combined with coordinated multidisciplinary care, were key to a favorable outcome. This case underscores the importance of considering Boerhaave’s syndrome in atypical presentations and acting swiftly when classical signs do appear.

Objective: To retrospectively assess the association of mediastinal, cardiovascular and pleuropulmonary findings on chest CT of 40 patients with immunohistochemically and histologically proven Erdheim-Chester disease (ECD). Methods: The multidetector chest CT images of 40 ECD patients were reviewed in consensus by chest and cardiovascular radiologists. Results: Thirty-four (85%) patients had periaortic infiltration that extended around the aortic branches of 29 (73%). Perivascular infiltration extended into the cardiac sulci in 22 (55%) ( p  < 0.005). Infiltration involved the right atrium wall in 12 patients, associated with severe narrowing of the atrial lumen in 8. Pericardial effusion and/or thickening were observed in 24 (60%) patients. Lung involvement, seen in 22 (55%) patients, was associated with mediastinal infiltration (20; p < 0.005) and pleural thickening or effusion (16; p  = 0.001); it consisted of smooth interlobular septa (21), subpleural thickening (13), poorly defined centrilobular nodular opacities (9), ground-glass opacities (8) and/or lung cysts (5). Conclusion: The detailed description of thoracic ECD involvement seen in these patients showed that infiltration into the mediastinal spaces including the pericardium, coronary sulci and right atrium is frequently associated with pleural and interstitial lung diseases.

Background: There are few published studies about the usefulness of endobronchial ultrasound (EBUS) in patients infected with human immunodeficiency virus (HIV). The clinical spectrum of likely diseases in this population is varied and differs from patients not infected with HIV. Objective: The aim of this study was to measure the usefulness of EBUS-guided transbronchial needle aspiration (EBUS-TBNA) in HIV-infected patients with mediastinal lymphadenopathy. Materials and Methods: We conducted an observational, cross-sectional, retrospective, descriptive study on patients with HIV infection and mediastinal lymphadenopathy who underwent EBUS-TBNA between September 2014 and April 2016. The patients' final diagnosis, regardless of the sample from which it was obtained, was considered the positive gold standard, and the absence of diagnosis was the negative. The study measured diagnostic accuracy of bronchoalveolar lavage (BAL), transbronchial biopsy (TBB), and EBUS-TBNA. Results: A total of 43 procedures were performed; 79.1% (34/43) of the patients were male, and the median age was 35 years (range, 22-66). The overall diagnostic yield including all types of samples was 90.7% (39/43); the yield of BAL was 50% (21), that of TBB 61.9% (26), and that of EBUS-TBNA was 60.5% (26). The combined yield of BAL with TBB was 69.8% (30); the yield of BAL with EBUS-TBNA was 86% (37) and that of TBB with EBUS-TBNA was 88.4% (38). The highest diagnostic accuracy was 97.7% for the combination of TBB and EBUS-TBNA. Conclusions: The most common infectious diagnoses were tuberculosis, with a higher diagnostic accuracy using EBUS-TBNA than BAL. With malignancies, both EBUS-TBNA and TBB were useful. EBUS-TBNA is a minimally invasive diagnostic tool that should be considered in these patients.

A man in his early 30s presenting with chest pain was admitted for the management of acute pericarditis and evaluation of a subcarinal mass incidentally noted on chest imaging. Shortly after admission, he developed cardiac tamponade. Emergent pericardiocentesis revealed purulent pericardial fluid with polymicrobial anaerobic bacteria, raising concern for gastrointestinal source and broad intravenous antibiotics were given. The pericardial fluid reaccumulated despite an indwelling pericardial drain and intrapericardial fibrinolytic therapy, necessitating a surgical pericardial window. Concurrent fluoroscopic oesophagram demonstrated oesophageal perforation with fistulous connection to the subcarinal mass and mediastinal drain, suggestive of oesophagopericardial fistula. Pathology from biopsy of the subcarinal mass returned with focal large necrotising granulomas consistent with histoplasmosis. Antifungal treatment was initiated, and the patient was eventually discharged home with nasogastric feeding tube and oral antibiotics and antifungals. This is the first reported case of polymicrobial pericarditis secondary to acquired oesophagopericardial fistula likely induced by mediastinal histoplasma lymphadenitis.

Background Recent studies showed that stent grafting is a promising technique for treatment of esophageal perforation. However, the evidence of its benefits is still scarce. Methods Forty-three consecutive patients underwent stent grafting for esophageal perforation at the Oulu University Hospital, Finland. The main endpoints of this study were early and mid-term mortality. Secondary outcome endpoints were the need of esophagectomy and additional surgical procedures on the esophagus and extraesophageal structures. Results Patients’ mean age was 64.6 ± 13.4 years. The mean delay to primary treatment was 23 ± 27 h. The most frequent cause of perforation was Boerhaave’s syndrome (46.5%). The thoraco-abdominal segment of the esophagus was affected in 58.1% of cases. Minor primary procedures were performed in 25 patients (58.1%) and repeat surgical procedures in 23 patients (53.5%). Forty-nine repeat stent graftings were performed in 22 patients (50%). Two patients (4.7%) underwent esophagectomy, one for unrelenting preprocedural stricture of the esophagus and another for persistent leakage of a perforated esophageal carcinoma. The mean length of stay in the intensive care unit was 6.0 ± 7.5 days and the in-hospital stay was 24.3 ± 19.6 days. In-hospital mortality was 4.6%. Three-year survival was 67.2%. Conclusions Stent grafting seems to be an effective less invasive technique for the treatment of esophageal perforation. Repeat stent grafting and procedures on the pleural spaces are often needed to control the site of perforation and for debridement of surrounding infected structures. Stent grafting allows the preservation of the esophagus in most of patients. The mid-term survival of these patients is suboptimal and requires further investigation.

A 70-year-old man with untreated diabetes mellitus was admitted to our hospital presenting with fever and malaise. He had slipped and fallen on the street a month before. A CT scan revealed a mediastinal abscess, right pneumothorax, and T2/3 spine destruction (figures 1–3.). MRI showed vertebral osteomyelitis, an epidural abscess, and an adjacent mediastinal abscess (figures 4–6). Blood culture was positive for Streptococcus intermedius. Vegetation was not detected by transthoracic echocardiography and repeated blood culture was negative after antimicrobial therapy. Endoscopy revealed that the oesophagus and trachea were intact.