A case of esophageal perforation associated with pharyngotonsillitis and Streptococcus anginosus group infection

Esophageal perforation is most commonly caused by foreign body ingestion, medical procedures, or spontaneous rupture. In contrast, perforation secondary to bacterial infection is extremely rare, particularly in immunocompetent individuals.

A previously healthy 60-year-old man developed pharyngotonsillitis followed by progressive right-sided chest pain. Initial chest radiography showed no abnormalities; however, subsequent computed tomography performed after clinical deterioration revealed right-sided empyema and an intramural abscess of the esophageal wall. Despite chest drainage and broad-spectrum antibiotics, the patient's respiratory status worsened, necessitating transfer to our hospital. Upper gastrointestinal endoscopy demonstrated extensive circumferential esophageal ulceration with purulent discharge. Streptococcus constellatus, a member of the Streptococcus anginosus group, was isolated from pleural fluid cultures. Because of severe infection, extensive empyema, and marked fragility of the esophageal wall, thoracoscopic total thoracic esophagectomy with a two-stage reconstruction strategy was performed. The postoperative course was favorable, and delayed reconstruction using a gastric conduit was successfully completed.

This case suggests that streptococcal pharyngotonsillitis may be associated with life-threatening esophageal perforation and empyema even in immunocompetent patients. Early recognition of disease progression and timely surgical intervention are essential in severe infectious cases.