Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 9 3 2025 10 08 e26 e26 Sepideh Aarabi Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran 2025 07 20 2025 09 29 Spontaneous esophageal perforation, also known as Boerhaave syndrome, is a rare but potentially fatal condition that classically presents with chest pain, vomiting, and subcutaneous emphysema. Atypical presentations can lead to diagnostic delays and increased morbidity and mortality rates. A 51-year-old male presented to the emergency department with isolated left flank pain. The CT scan unexpectedly revealed bilateral diffuse subcutaneous emphysema and left pleural effusion. Following chest tube insertion, food particles were recovered from the pleural drainage, which established the diagnosis of esophageal perforation. Emergency surgical repair was performed successfully with a good clinical outcome. This case highlights the importance of maintaining high clinical suspicion for esophageal perforation even in patients presenting with atypical symptoms. The absence of classic triad symptoms should not exclude this diagnosis from consideration. CT imaging can provide crucial diagnostic information when the clinical presentation is unclear or atypical. https://fem.tums.ac.ir/index.php/fem/article/view/1626 https://fem.tums.ac.ir/index.php/fem/article/download/1626/530