Ernesto Robalino Gonzaga
University of Central Florida College of Medicine
Esophageal rupture is an uncommon pathology but carries high mortality and morbidity if not recognized early. Rupture can occur in healthy individuals, but damaged epithelium and increased intra-esophageal pressure make the pathology more likely. Outcomes depend on the extent of rupture, intra-thoracic complications and timely intervention. This case highlights “Kambo” frog cream used for “ritual cleansing” which induced vomiting leading to rupture.
A 62 year-old woman with a past medical history of alcohol dependence presented to the ER with shortness of breath, severe epigastric pain, nausea and non-bloody emesis one day after using “Kambo” frog poison topical cream. Physical exam revealed tachycardia and oxygen saturation 95%. She exhibited decreased breath sounds and crepitus on palpation near the base of the neck and epigastric tenderness. STAT chest X ray and chest CT showed large left sided tension pneumothorax and pneumomediastinum due to esophageal perforation. A chest tube was placed and intubation for airway protection was performed. The patient underwent uneventful esophageal repair via left thoracotomy and primary repair of esophageal perforation with placement of intercostal muscle flap. Patient’s post-operative course was uneventful. Patient was discharged home after 7 days post surgery.
Discussion: Esophageal rupture can lead to multiple complications, such as mediastinitis, pleural effusions, cardiac tamponade, and sepsis. Kambo frog poison is obtained from the secretions of the amazon tree frog, Phyllomedusa bicolor, and has been used in traditional ritual for body cleansing. There is little medical evidence of Kambo’s medicinal use and its use carries great risks, including sudden death.
Management of this pathology depends on hemodynamic status of the patient and location of perforation. Conservative management can be considered in hemodynamically stable patients with contained perforation. Unstable patients or those with evidence of diffuse extravasation at site of perforation, progression of pneumomediastinum or pneumothorax, or development of empyema require immediate surgical intervention via open thoracotomy. Endoscopic management can be considered for patients with high risk surgical intervention. Multiple techniques including stent placement, stent with endoscopic suturing or endoluminal vacuum therapy can be utilized.
Moderate size left upper chest pneumothorax 4.4cm, mildly displaced trachea rightward from developing tension pneumothorax. Subcutaneous emphysema in cervicothoracic region, pneumomediastinum.
There is a large left pneumothorax under tension associated with a large left pleural effusion and significant airspace disease. The finding are related to a distal esophageal perforation which appears to also be resulting in a gastrointestinal bleed.
Ernesto Robalino Gonzaga indicated no relevant financial relationships.
Maria Chamorro indicated no relevant financial relationships.
Robert Schneider indicated no relevant financial relationships.
Wojciech Blonski indicated no relevant financial relationships.