"Cardiomegaly and pneumonia," a misdiagnosis in long-standing achalasia

History: A 65-year-old woman was admitted to another hospital with suspecte d status asthmaticus. While there was progressive respiratory failure, the chest X-ray showed bilateral congestion and infiltration with widened media stinum and cardiomegaly. The patient was transferred to the authors' hospit al after two days on ventilatory support because of suspected left-ventricu lar failure and pulmonary congestion with pneumonia. 30 years previously sh e had undergone a myotomy for achalasia. Investigations: Imaging of the oesophagus with water-soluble contrast mediu m, computed tomography of the thorax and gastroscopy revealed a siphon-like megaoesophagus (which had been misinterpreted radiologically as cardiomega ly) with a slightly open lower oesophageal sphincter. The pulmonary symptom s were thought to be due to aspiration pneumonia. Treatment and course: As there were no other reasonable treatment options a transmediastinal oesophageal resection with gastric pull-through and colla r anastomosis was performed. Conclusion: In long-standing achalasia a megaoesophagus can develop despite previous myotomy. It should be included in the differential diagnosis of r adiologically demonstrated mediastinal enlargement.