B73-03 Mediastinal Paratracheal Abscess With Tracheal Fistula Due to Pseudomonas Aeruginosa: A Rare and Fatal Complication of Nasogastric Tube Placement

Abstract Nasogastric tube (NGT) placement is a routine bedside procedure frequently performed in intensive care units. Although considered relatively low risk, malposition or perforation can result in devastating complications such as mediastinitis, abscess formation, and tracheal fistula. These outcomes, though rare, carry high morbidity and mortality, highlighting the need for vigilance and early recognition. A man in his early 60s was admitted to the intensive care unit (ICU) with acute respiratory failure secondary to aspiration pneumonia. He was endotracheally intubated, and an NGT was placed. Follow-up chest radiography demonstrated appropriate NGT positioning in the gastric fundus, and enteral feeding was initiated. The patient was empirically started on cefepime and vancomycin for suspected aspiration pneumonia. Despite broad-spectrum antibiotics, the patient developed worsening leukocytosis (22,000 WBC) with neutrophilic predominance, elevated procalcitonin at 32 ng/mL, ESR at 126 mg/dL, and CRP at 300 mg/L. Serial chest CT revealed NGT-related hypopharyngeal perforation with esophageal dissection, the tube coursing through the prevertebral space before re-entering the stomach, and a fluid collection (4.3 × 7.6 × 1.0 cm) entrapping the distal trachea, carina, and bilateral bronchi—findings consistent with a mediastinal abscess Figure A and B. ENT, thoracic surgery, and pneumology were consulted. Tracheoscopy identified a tracheal fistula Figure C and D with copious purulent secretions at the right aspect of the trachea draining to the right main bronchus (RMB), not previously identified by CT imaging. A pigtail catheter was placed for abscess drainage. Cultures grew extended-spectrum β-lactamase (ESBL) Pseudomonas aeruginosa and multi-drug sensitive (MDS) Proteus mirabilis, prompting antibiotic adjustment to vancomycin and meropenem. Due to the patient’s clinical instability, surgery was deemed too high risk by cardiothoracic surgery. Despite aggressive management, he died after eight days of hospitalization. Mediastinal abscesses are most often associated with cardiothoracic surgeries, trauma, or anatomical adjacent infections. NGT-induced mediastinitis is exceedingly rare but potentially fatal. This case underscores the importance of meticulous technique and vigilance during NGT placement, as complications from a seemingly simple procedure can result in life-threatening sequelae, including abscess and tracheal fistula formation This abstract is funded by: none