Nasogastric tube migration through a distal esophageal perforation into the pleural space in a nonagenarian woman with recurrent empyema: a case report

Background Nasogastric tube (NGT) placement is frequently used for enteral access in critically ill patients. Esophageal perforation with intrapleural tube migration is rare but can cause major pleural contamination, infection, and respiratory complications. We report an unusual case of recurrent right-sided empyema associated with an NGT traversing a distal esophageal perforation into the right pleural cavity. Case presentation A 90-year-old woman with severe neurological impairment, tracheostomy, and chronic mechanical ventilation was transferred on 11 October 2023 for recurrent right pleural empyema. Chest CT on 12 October showed the distal nasogastric tube (NGT) within the right pleural space, associated with effusion and gas suggestive of esophago-pleural communication. On 14 October, she underwent esophageal repair and right lung decortication. The treating thoracic surgeon reported to the ICU physician in charge an approximately 1 cm lower-third esophageal perforation traversed by the NGT. Histopathology showed inflamed pleural tissue and organizing pneumonia; pleural pus culture yielded moderate growth of vancomycin-resistant Enterococcus faecium, susceptible to linezolid and resistant to vancomycin, ampicillin, penicillin, ciprofloxacin, and levofloxacin. After an inconclusive study and CT concern for a postoperative leak on 22 October, endoscopy and fluoroscopic contrast assessment on 23 October found no gross perforation or contrast leak; the NGT was advanced into the stomach under endoscopic guidance. Enteral feeding was subsequently tolerated. On 31 October, the last available clinical assessment, she was hemodynamically stable but remained ventilator-dependent. The administrative discharge entry on that date represented monthly billing rather than physical discharge. Conclusions Enteral-feed-like material in a pleural drain should prompt urgent evaluation for gastrointestinal–pleural communication and feeding-tube malposition. CT can define the abnormal tube course and associated thoracic complications. This case highlights the importance of reliable NGT position verification before use and prompt multidisciplinary source control when esophageal perforation is accompanied by pleural contamination.