Mediastinitis caused by infection with Clostridium perfringens and spontaneous rupture of the esophagus are both life threatening conditions. The combination of these two entities led to septic multiorgan failure in a 38-year-old woman. The patient was treated successfully by esophagectomy and postoperative lavage through a partially open abdomen. The lack of information regarding emesis, the leading symptom of Boerhaave's syndrome, caused delayed diagnosis: the triad of emesis, severe epigastric pain and emphysema of the skin was not established until 30 h after the onset of symptoms.