Semaglutide reinitiation at high dose linked to first reported Boerhaave's syndrome case

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are increasingly prescribed for type 2 diabetes and weight loss, known for gastrointestinal side effects like nausea and delayed gastric emptying. While mucosal injuries such as Mallory-Weiss tears have been reported, full-thickness esophageal perforation has not been previously described. This case report addresses this gap by detailing the first documented instance of Boerhaave's syndrome associated with GLP-1 RA use, highlighting a rare but potentially fatal complication.

This case report describes a previously healthy woman in her 50s who presented with severe nausea, emesis, and acute chest pain. She had restarted semaglutide at the maximum 2.4 mg weekly dose the day prior to symptom onset, after several months off therapy and without dose titration. Diagnostic imaging revealed pneumomediastinum and bilateral pleural effusions, with an esophagram confirming a contained esophageal perforation. Her clinical course and subsequent management were meticulously documented.

The patient presented in vasopressor-dependent shock and respiratory failure, requiring intubation. Initial management included endoscopic stent placement, nasojejunal feeding, and chest tube drainage, leading to clinical improvement and discharge. > Two months later, she was readmitted with necrotizing pneumonia, revealing an esophagopleural fistula, abscess, and migrated stent. She underwent left thoracotomy, abscess drainage, decortication, and wedge resection of necrotic lung, with the perforation site reinforced by an intercostal muscle flap and a PEG tube placed. Postoperatively, at 10-month follow-up, she was on a regular diet, the PEG tube was removed, and her esophagus was healed on EGD. She was advised to permanently discontinue GLP-1 RAs.