A Case of Achalasia and Aspiration Pneumonia in a Young Adult

Achalasia is an uncommon primary esophageal motility disorder characterized by impaired lower esophageal sphincter relaxation and absent esophageal peristalsis. These changes result in progressive esophageal dilation and functional obstruction. Although classically associated with dysphagia and regurgitation, respiratory manifestations may predominate due to chronic aspiration of retained esophageal contents, which can obscure the underlying diagnosis and delay appropriate management. We report the case of a 20-year-old male with a history of asthma, gastroesophageal reflux disease, and gastroparesis who presented with one day of shortness of breath and productive cough, initially treated as an asthma exacerbation. Imaging performed to evaluate new-onset respiratory symptoms for one day prior to admission revealed a markedly dilated, fluid-filled esophagus and radiographic findings consistent with aspiration pneumonia. He was initially treated with one dose of 2 mg IV cefepime, then modified to Unasyn 3 mg and doxycycline 100 mg. Subsequent endoscopic evaluation confirmed severe esophageal dilation with retained food contents, supporting the diagnosis of advanced achalasia. This case highlights how achalasia may present primarily with pulmonary complications in young patients, particularly when coexisting respiratory disease is present. Delayed recognition can result in significant morbidity, including recurrent aspiration, malnutrition, and progressive esophageal dysfunction. Early consideration of esophageal motility disorders in patients with refractory respiratory symptoms and GI history is essential to prevent complications and guide timely therapeutic intervention.