Case Presentation: A 79-year-old woman with well-controlled hypertension and diabetes mellitus presented to her primary care physician’s office with two weeks of constant, right-sided clear nasal discharge that began one week after discharge from recent hospitalization for septic shock secondary to E. coli urinary tract infection with associated bacteremia. Her physician recommended therapies for allergic rhinitis which were ineffective despite adherence. Additional consultation with an otolaryngologist led to similar recommendations. The patient subsequently developed severe headaches, vomiting, and confusion. Head imaging revealed pneumocephalus, and a lumbar puncture was remarkable for S. pneumoniae meningitis. She was admitted to the intensive care unit and started on appropriate therapies for acute bacterial meningitis with rapid correction of her encephalopathy. Ultimately, she received an endoscopic repair of visualized skull base defect with nasoseptal flap prior to discharge.

Discussion: Clear rhinorrhea from only one side is consistent with a cerebrospinal fluid (CSF) leak, which can lead to pneumocephalus and bacterial meningitis. Given the time frame of this patient’s CSF leak appearing shortly after her previous hospitalization for septic shock, it is believed that she experienced CNS penetration as a complication of her NGT placement during that hospitalization.

Conclusions: CNS penetration as a complication of NGT placement is a rare and potentially deadly complication of a common procedure. The most common complication of NGT placement is tube malfunction. CNS penetration most often occurs with preceding facial trauma and associated facial fractures, though it has also been observed after recent craniofacial surgery. To our knowledge, this is the only documented case of CNS penetration leading to pneumocephalus and bacterial meningitis as a complication of NGT placement in a patient without prior head trauma or recent surgical procedures. This case serves to emphasize the importance of appropriate, careful NGT placement as complications can occur even months after placement.