Peritoneal-Mediastinal Dialysate Leak Presenting as Chest Pain in a Patient on Peritoneal Dialysis

Peritoneal dialysis (PD)-related leaks are usually pleuroperitoneal; mediastinal extension is exceptionally rare. A 38-year-old man with ESKD due to immune complex-mediated focal segmental glomerulosclerosis on long-term automated PD presented with acute exertional chest pain mimicking an acute coronary syndrome. Cardiac biomarkers were elevated, but electrocardiography and coronary angiography showed no ischemic disease. Computed tomography pulmonary angiography excluded pulmonary embolism and revealed a paraesophageal fluid collection. Contrast-enhanced computed tomography after intraperitoneal instillation of iodinated dialysate confirmed mediastinal leakage through the esophageal hiatus. Increased intra-abdominal pressure and an umbilical hernia were identified as risk factors. PD withdrawal and transition to hemodialysis led to complete resolution. Mediastinal dialysate leakage should be considered in PD patients with unexplained chest pain; computed tomography peritoneography is diagnostic.