Cytologic Findings in Esophageal Perforation: An Institutional Experience With Pleural Fluid Specimens

Esophageal perforation (EP) is a rare but life-threatening condition, and most cases are due to iatrogenic causes. The rest occur spontaneously, due to malignancies, or trauma. The mortality rates can approach 50%, and delayed diagnosis of EP exacerbates patient outcomes. Cytologic recognition of pleural fluid specimens with oropharyngeal contents (e.g., squamous cells, Candida species) or food/foreign material can expedite the diagnosis of EP. This study presents our institution's experience with cytologic findings in EP patients.

We reviewed our institutional database over a 25-year period to identify pleural fluid cytology specimens from EP patients. Data on patient demographics, clinical history, and microbiology culture results were collected. Slides were assessed for squamous cells, food/foreign material, and infectious organisms.

Eleven pleural fluid cytology specimens from 10 patients with EP (seven males, three females; mean age 68 years) were retrieved. Three cases were atypical, and eight were negative for malignancy. Mortality occurred in four (40%) patients within a mean of 2.2 months post-EP diagnosis. The majority of EP causes were iatrogenic (82%) or associated with malignancy (55%). Squamous cells were present in 27% of specimens, while food/foreign material and fungi were identified in 36% and 9% of cases, respectively. Cultures were positive in seven (64%) patients, with 46% showing bacterial growth and 55% positive for fungal organisms.

Our experience corroborates that EP carries a high mortality risk, underscoring the need for prompt diagnosis. Although Candida species were present in only a small subset of pleural fluid samples, the presence of squamous cells or food/foreign material is a helpful diagnostic clue of EP, particularly in patients with a history of recent medical manipulation or malignancy involving the esophagus. Our findings highlight the potential of identifying involved pleural fluid cytology specimens to decrease the time to diagnosis of EP.