Suspected iatrogenic oesophageal perforation presenting as right-sided pneumothorax in a preterm neonate: Diagnostic challenges and management

Iatrogenic oesophageal perforation (IOP) is a rare but potentially fatal complication of orogastric (OG) or nasogastric tube insertion in preterm neonates, with mortality rates up to 30%. We describe the case of a female neonate born at 31 + 5 weeks of gestation (birth weight 1.8 kg) who required extensive resuscitation and OG tube insertion after admission to the neonatal intensive care unit. Admission chest radiograph showed right-sided pneumothorax with OG tube aberrantly positioned in the right hemithorax which was missed initially. Following intercostal drain insertion and commencement of enteral feeds, milky pleural drainage was observed. Normal pleural triglyceride levels excluded chylothorax, prompting radiographic re-evaluation and paediatric surgical review, leading to diagnosis of IOP. Despite conservative management, the infant developed septic shock with sclerema and died on the 4 ^th day of life. This case emphasises careful radiographic confirmation of tube placement in preterm neonates and the diagnostic significance of milky pleural drainage following feeds