A case of spontaneous rupture of the esophagus without contrast leakage on esophagography

A 34-year-old man was transferred to the emergency room of our hospital because of vomiting, diarrhea, and epigastralgia 1 day after drinking alcohol and eating raw fish. He was provisionally diagnosed with acute enteritis and admitted to our hospital. He was treated by a non-per-oral approach with hydration and antibiotics. CT at the admission revealed pneumomesiastinum. The next day, although esophagography revealed no contrast leakage, computed tomography revealed a shadow thought to be an abscess in the area of the middle mediastinum, surrounded by the diaphragm, descending aorta, and esophagus, along with left pleural effusion. Therefore, we diagnosed him with spontaneous rupture of the esophagus, and thoracic/mediastinal drainage was urgently performed that night via left video-assisted thoracic surgery. Streptococcus parasanguinis was detected in the abscess and Streptococcus intermedius in the pleural effusion. He restarted drinking water on post operative day （POD）9 and eating on POD11. He was treated by antibiotics until POD14 and discharged on POD17. Spontaneous rupture of the esophagus can be definitively diagnosed when esophagography reveals contrast leakage, although there are rare cases without leakage, similarly to the present case. It is important not to hesitate to perform surgical treatment in cases suspected of having spontaneous rupture of the esophagus based on the clinical course and other imaging findings besides esophagography.