When Textbook Meets Reality: A Rare Case of Boerhaave's Syndrome With Mackler's Triad

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.