A53-33 The Polymicrobial Conundrum: Esophageal Perforation and Persistent Fungemia, Polymicrobial Sepsis With Septic Emboli

Esophageal perforation is a rare but catastrophic emergency with an incidence of approximately 3 per million annually and mortality approaching 60% in critically ill patients. Most cases arise from iatrogenic injury (46%), spontaneous rupture (Boerhaave syndrome, ∼30%), or trauma. Thoracic perforations account for nearly three-quarters of cases and are often complicated by polymicrobial bacteremia, pleural contamination, and systemic fungal infection, which occurs in up to 59% and doubles mortality. We present a case of occult esophageal perforation presenting with persistent polymicrobial bacteremia, fungemia, and septic emboli. A 74-year-old male with no significant past medical history was found unresponsive in a pool of blood of unclear duration. On arrival, he was hypotensive (MAP 59 mmHg), mildly hypothermic (95 °F), and required oxygen supplementation. Examination revealed facial bruising, scalp hematoma, poor dentition, and coarse bilateral lung crackles without focal neurologic deficits. Laboratory studies showed leukocytosis (25.5 × 109/L), lactate 2.9 mmol/L, creatinine 2.8 mg/dL, and metabolic acidosis. CT chest revealed right upper lobe consolidation, bilateral peribronchovascular opacities, and circumferential esophageal thickening. Blood cultures grew Enterococcus faecalis and Proteus vulgaris within hours, followed by Candida glabrata on repeat cultures despite antifungal therapy. The patient developed respiratory failure and septic shock requiring intubation and norepinephrine. Repeat imaging showed new bilateral infiltrates and pleural effusions; thoracentesis yielded exudative fluid with elevated amylase (112 U/L). MRI brain demonstrated multifocal ischemic foci consistent with septic emboli. Esophagogastroduodenoscopy identified a large distal esophageal perforation with an adjacent necrotic cavity, confirming the source of polymicrobial sepsis. Due to multiorgan failure, he was not a surgical candidate and transitioned to comfort measures. This case emphasizes the importance of maintaining suspicion for gastrointestinal (GI) perforation in patients with sepsis of unclear source, particularly with polymicrobial or fungal bloodstream infections. Persistent fungemia despite antifungal therapy should prompt investigation for occult GI perforation. Early imaging findings such as esophageal thickening or mediastinal changes may be subtle yet crucial. Septic emboli reflect hematogenous dissemination secondary to mucosal breach. Delayed recognition frequently results in multiorgan failure and high mortality, highlighting the need for multidisciplinary involvement and rapid diagnostic escalation. In critically ill patients with persistent polymicrobial bacteremia or fungemia, occult GI perforation must remain high in the differential even when imaging is nonspecific. Early endoscopic evaluation, timely source control, and coordinated management are essential to improve survival. References: DeVivo A et al. Am J Emerg Med. 2022;53:29-36., Sdralis EIK et al. Dis Esophagus. 2017;30(8):1-6. This abstract is funded by: None