A 67-year-old man (mongoloid race, Japanese) was admitted to our hospital because of a 3-day history of fever. Acid-fast bacilli was found to be smear-positive in his sputum, and a chest radiograph and computed tomography examinations showed parenchymal opacities with scattered fine nodules in his right apical region. He was diagnosed with pulmonary tuberculosis, so he was started on anti-tuberculosis therapy with isoniazid, rifampicin, ethambutol, and pyrazinamide on the first day that he was hospitalized. He had developed a cerebral hemorrhage 18 months before this hospitalization, and he had right hemiplegia, dysphagia, and aphasia as sequelae. He had been receiving 600 kcal/day of liquid nutrition via a nasogastric tube for 6 months before the current hospitalization.
On admission to our hospital, he had a 16.5 cm x 15.5 cm, grade IV pressure ulcer in the sacral region, from which Escherichia coli and methicillin-resistant Staphylococcus were detected (Figure 1, panel A). His albumin count was 2.2 g/dL, hemoglobin was 11.1 g/dL, C-reactive protein was 12.0 mg/dL (Figure 2) and his body temperature was 38 C. A liquid nutrition of 200 kcal was administered for 60 minutes, 3 times a day, and this regimen was continued for 2 weeks. In order to improve his state of nutrition and to reduce weight-bearing on the sacral region, 1,200 kcal/day of liquid nutrition was administered for a shorter time. This, however, induced watery diarrhea and gastroesophageal reflux. His general condition and malnutrition (low serum albumin) suggested that he would have a poor prognosis if a gastrostomy was performed. It was difficult to confirm whether or not he would accept gastrostomy feeding, so nasogastric tube feeding was continued. As for the preparation, we selected semi-solid nutrition with higher viscosity (20,000 mPa x s). In order to achieve the administration in a certain short period of time, a nasogastric tube of 18 French was inserted.
As the patient was febrile and bedridden, his total energy expenditure was assessed as 1,708 kcal/day by the Harris-Benedict equation (presumed height 162 cm, presumed body weight 45 kg, ideal body weight 57.7 kg, activity factor = 1.1, stress factor = 1.5). Considering that his caloric prescription up to that time had been 600 kcal/day and he had diarrhea, we first tried 1,200 kcal/day.
On day 21 in hospital, a semi-solid enteral product of 400 kcal/267 g (PG Soft , Terumo, Tokyo, Japan) was administered for 15 minutes 3 times a day, which was then followed by 250 mL of semi-solidified water (PG Water , Terumo, Tokyo, Japan) and dietary fiber. After starting the semi-solid enteral product, he experienced no diarrhea or esophageal reflux. On day 22, a debridement of the sacral pressure ulcer was conducted. Four weeks later, an improvement was observed in his albumin, hemoglobin, and C-reactive protein levels (Figure 2). His pressure ulcer was then 8.0 cm x 5.0 cm (Figure 1, panel D).
No complication of the esophagus, paranasal sinus, or nose wings accompanying insertion of the nasogastric tube was observed. Compliance of the large-bore nasogastric tube was favorable, and he did not try to remove the tube himself. With continuous maintenance of the tube, no obstruction was observed. Administration of anti-tuberculosis drugs was continued via the nasogastric tube without any adverse effects, and tubercle bacillus was not detected in his sputa. After 3.5 months, he was transferred to another facility for further recuperation.