Background: Many patients have a nasogastric feeding tube inserted during admission; however, misplacement is not uncommon. In this case report we present, to the best of our knowledge, the first documented fatality from pressure pneumothorax following nasogastric tube withdrawal. 

Case presentation: An 84-year-old Caucasian woman with dysphagia and at risk of aspiration underwent routine insertion of a nasogastric feeding tube; however, shortly after insertion she developed respiratory distress. A chest X-ray showed the tube had been misplaced into our patient's right lung. The tube was removed, but our patient died less than an hour after withdrawal. The autopsy report stated that cause of death was tension pneumothorax, which developed following withdrawal of the misplaced feeding tube. 

Conclusions: The indications for insertion of nasogastric feeding tubes are many and the procedure is considered harmless; however, if the tube is misplaced there is good reason to be cautious on removal as this can unmask puncture of the pleura eliciting pneumothorax and, as this case report shows, result in an ultimately deadly tension pneumothorax.