“Nutrothorax” complicating a misplaced nasogastric feeding tube in a severely ill patient

Introduction of nasogastric feeding tubes is usually blindly performed and isgenerally considered a safe procedure. However, the rate of complications ofa blind insertion technique varies from 0.3 to 15%, and is usually related toinadvertent insertion of nasogastric tubes into the trachea and distal airways.The main predisposing factors related to tube malpositioning and complicationsare altered mental status with decreased cough or gag reflex, a preexistingendotracheal tube and severe illness. Complications include severe aspirationpneumonia, hydrothorax, hemothorax, empyema and pneumothorax. Themortality related to misplacement of a nasogastric tube is around 0.1-0.3% ofthe procedures. This 61-year old female had a history of poor appetite, weightloss, dyspnea and fever. A chest axial computerized tomography showedenlarged mediastinal lymph nodes. Laboratory showed hypercalcemia withnormal PTH and hypokalemia. As the patient remained anorectic, a nasogastricfeeding tube was placed, through which the administration of enteral diet, bycontinuous infusion pump, was started. After 12 hours the patient developeddyspnea, hypoxemia and hypotension. During orotracheal intubation, itwas disclosed the presence of the nasogastric tube in the trachea as wellas the infused diet within the respiratory tract. Autopsy revealed an unusualcomplication of a nasogastric tube misplacement, which led to a massivecollection of enteral nutrition fluid into the pleural space – a “nutrothorax”.Additionally, an underlying stage IV anaplastic large cell lymphoma withinterstitial lung and bronchial mucosa involvement was diagnosed