Could a patient with Herpes Simplex Virus type 1 (HSV-1) Encephalitis and underlying autoimmune diseases, who has failed swallowing tests and experienced prolonged pneumonia with a Nasogastric (NG) tube in place since diagnosis, be at increased risk of complications due to aspiration or other related factors?

From the Guidelines

Yes, the patient with Herpes Simplex Virus type 1 (HSV-1) Encephalitis and underlying autoimmune diseases, who has failed swallowing tests and experienced prolonged pneumonia with a Nasogastric (NG) tube in place since diagnosis, is at increased risk of complications due to aspiration or other related factors. The presence of an NG tube in a patient with impaired swallowing function, as seen in HSV-1 encephalitis, increases the risk of aspiration pneumonia because it can interfere with the normal protective mechanisms of the upper airway and esophageal sphincter 1. Additionally, autoimmune diseases may contribute to overall immune dysfunction, making it harder for the patient to clear respiratory infections. The combination of impaired swallowing from the encephalitis, the physical presence of the NG tube, and potentially compromised immunity creates a high-risk situation for aspiration and persistent pneumonia. Some key points to consider in managing this patient include:

• Early dysphagia screening is recommended for acute stroke patients to identify dysphagia or aspiration, which can lead to pneumonia, malnutrition, dehydration, and other complications 1.
• Alternative feeding methods such as a percutaneous endoscopic gastrostomy (PEG) tube might be considered if long-term enteral nutrition is needed, as PEG tubes are associated with lower aspiration risk compared to NG tubes 1.
• Regular oral care, proper positioning during and after feedings (30-45 degree elevation), and ensuring proper NG tube placement can help reduce pneumonia risk while the NG tube remains necessary 1.
• The risk of aspiration pneumonia is not eliminated by the use of an NG or PEG tube, and other measures such as swallowing assessments and instrumental evaluations may be necessary to guide treatment plans 1. It is essential to weigh the benefits and risks of different feeding methods and to consider the individual patient's needs and circumstances when making decisions about their care. In this case, the patient's prolonged pneumonia and failed swallow tests suggest that alternative feeding methods, such as a PEG tube, may be necessary to reduce the risk of aspiration and improve outcomes 1.

From the Research

Risk of Complications

• A patient with Herpes Simplex Virus type 1 (HSV-1) Encephalitis and underlying autoimmune diseases, who has failed swallowing tests and experienced prolonged pneumonia with a Nasogastric (NG) tube in place since diagnosis, may be at increased risk of complications due to aspiration or other related factors 2, 3, 4, 5.
• The use of a Nasogastric tube (NGT) can lead to complications such as lesions to the nasal wing, chronic sinusitis, gastro-oesophageal reflux, and aspiration pneumonia 4, 5.
• Percutaneous endoscopic gastrostomy (PEG) tube feeding may be a better option than NGT for patients with swallowing disturbances, as it is associated with a lower probability of intervention failure and may reduce the risk of pneumonia requiring hospitalization 6, 3, 4, 5.

Aspiration Pneumonia

• Aspiration pneumonia is a common cause of death in patients with oropharyngeal dysphagia, and the risk of pneumonia requiring hospitalization is significantly increased in older patients and in patients with neurological disorders, tube feeding, and oropharyngeal dysphagia 3.
• The risk of pneumonia requiring hospitalization was significantly lower in patients with PEG than in those with NGT among the patients with oropharyngeal dysphagia 3.
• Measures of immunodepression are associated with an increased risk of stroke-associated pneumonia (SAP) in dysphagic patients, and treatment with metoclopramide may reduce SAP risk 2.

Nutritional Support

• PEG tube feeding may improve outcome of late rehabilitation following stroke, and is associated with nutritional improvement, marked functional recovery, and eventual discharge from hospital 6.
• PEG was associated with a lower probability of intervention failure, suggesting the endoscopic procedure may be more effective and safe compared with NGT 4, 5.
• There is no significant difference in mortality rates between comparison groups, or in adverse events, including pneumonia related to aspiration 4, 5.