Pulmonary & Respiratory Medicine

Diagnosis of de novo esophageal rupture is generally obtained via esophagram. In this case, we present a patient with an esophageal tear, initially presenting as a non-resolving empyema, but ultimately diagnosed based on methylene blue administration at bedside. In the case of critically ill patients who are unable to tolerate more advanced studies, methylene blue delivered through a nasogastric or orogastric lumen is a rapid bedside test that can yield a diagnosis in patients with involvement of the pleural space. This case serves as a reminder of the importance of being cognizant of anchoring bias when evaluating patients, as well as the utility of methylene blue in evaluation of a suspected esophageal rupture.