Premature newborn after placement of an umbilical venous catheter

AXR of umbilical venous catheter tip in the right portal vein — AXR AP shows the course of the umbilical venous catheter taking a 90 degree turn within the liver with its tip projecting over the right lobe of the liver.

The diagnosis was umbilical venous catheter malfunction with the catheter tip projecting over the right portal vein.

Premature newborn after umbilical venous catheter placement

CXR of umbilical venous catheter perforation causing TPNoma in liver and TPN ascites — AXR AP (above left) after line placement shows the tip of the umbilical venous catheter to be inferior to the cavo-atrial junction. The bowel gas pattern is normal. There is a moderate right pleural effusion. AXR AP obtained 1 day later (above right) shows developing mild centralization of the bowel loops and increase in the size of the right pleural effusion. The tip of the umbilical venous catheter now projects over the umbilical vein. AXR AP obtained 1 day later (below left) shows marked centralization of bowel loops. Sagittal US of the right side of the abdomen (below right) shows a large right pleural effusion (left side of image), a large amount of ascites (right side of image anteriorly) and a cystic lesion within the liver (right side of image posteriorly).

The diagnosis was umbilical venous catheter malfunction due to perforation of the umbilical venous catheter out of the umbilical vein resulting in a TPNoma in the liver and TPN ascites.

Premature newborn after peripherally inserted central catheter placement

CXR of pediatric PICC line tip in a left-sided superior vena cava — CXR AP shows the tip of the left upper extremity PICC line projecting over the heart and to the left of the spine.

The diagnosis was peripherally inserted central catheter malfunction with the tip of the PICC line in a persistent left superior vena cava which was confirmed on an ultrasound exam.

Newborn with respiratory distress

CXR of normal position of arterial venous ECMO catheters — CXR AP shows multiple loops of small bowel that are minimally filled with air in the lower left hemithorax. There is mediastinal shift to the right. The tip of the arterial canula placed from the right carotid artery projects over the aortic arch while the tip of the venous canula placed from the right internal jugular vein projects over the right atrium. There are two chest tubes in the right hemithorax.

The diagnosis was normal position of the arterial canula and venous canula in a patient on extracorporeal membrane oxygenation due to left congenital diaphragmatic hernia.

School ager who is having difficulty using their central venous line

Central line injection of a fibrin sheath on a central venous catheter — AP image from a central line injection shows the distal part of the catheter is thicker than the rest of the catheter. Contrast was never seen to exit the tip of the catheter but instead was seen to exit the catheter from a position 2 cm above the tip of the catheter.

The diagnosis was central venous catheter malfunction in the form of a fibrin sheath along the distal catheter.

Infant with a central venous catheter placed 6 months ago that now cannot be infused through

CXR of central venous catheter migrating out of the superior vena cava over time — CXR AP obtained at placement (above left) shows the tip of the central venous catheter in the superior vena cava. CXR AP obtained 2 months after placement (above right) shows the tip of the central venous catheter to have migrated slightly back in the interval. CXR AP obtained 4 months after placement (below left) shows the tip of the central venous catheter to have migrated slightly further back in the interval. CXR AP obtained 6 months after placement (below right) shows the tip of the central venous catheter to have migrated out of the superior vena cava entirely.

The diagnosis was central venous catheter malfunction in the form of the catheter migrating slowly out of the superior vena cava.

Toddler with a central venous catheter that is difficult to infuse through and difficult to draw back from

Central catheter injection of thrombus at the tip of a central venous catheter — Scout image from a fluoro exam (left) shows the catheter is radiographically intact with its tip in the brachiocephalic vein. Images obtained during contrast injection (center and right) show contrast filling and outlining an irregularly shaped object at the tip of the catheter.

The diagnosis was central venous catheter malfunction due to a large thrombus at the tip of the catheter.

Toddler with a newly placed central venous catheter that can be infused through but cannot be drawn back from

Radiograph of central venous cathetertip flush against the wall of the superior vena cava — CXR AP (above) shows the tip of the central venous catheter to be flush against the wall of the superior vena cava. Image taken during contrast injection of the central venous catheter (below) show the tip of the catheter has moved away from the wall of the superior vena cava during injection.

The diagnosis was pediatric central venous catheter malfunction because the tip of the catheter is flush against the wall of the superior vena cava.

Newborn who developed an episode of cardiac decompensation

CXR of pericardial effusion due to catheter perforation into pericardial space — CXR AP obtained after left subclavian line placement (above) shows the tip of the line in the right atrium. CXR AP obtained 3 days later during the episode of cardiac decompensation (below) shows interval enlargement of the cardiac silhouette. ECHO showed the subclavian line had perforated into the pericardial space resulting in a hemopericardium.

The diagnosis was subclavian venous catheter malfunction due to it perforating into the pericardial space resulting in a pericardial effusion.

School ager whose pacemaker is not firing correctly

CXR of broken cardiac pacemaker lead. — CXR AP shows the cardiac pacemaker lead in the middle of the heart is not intact radiographically while the other two pacemaker leads are intact radiographically.

The diagnosis was cardiac pacemaker lead malfunction in the form of a pacemaker lead fracture.

Toddler with heterotaxy syndrome

US and upper GI of malrotation without midgut volvulus in heterotaxy syndrome — Transverse color doppler US of the abdomen (below left) shows an apparent reversal of the normal positions of the superior mesenteric artery and superior mesenteric vein. This is confirmed on the spectral doppler US of the aforementioned mesenteric vessels (above). AP image from an upper GI exam (below right) shows situs inversus with levocardia and the stomach in the right upper quadrant. The duodenum is redundant and the duodenal jejunal junction is over the right pedicle of the T11 vertebral body. The cecum was in the midline.

The diagnosis was malrotation without midgut volvulus in a patient with heterotaxy syndrome.

School ager with hypertension and neurofibromatosis Type 1

CT of midaortic syndrome — Axial CT with contrast of the abdomen shows the aorta to have a normal caliber in the upper abdomen (above left) and a markedly decreased caliber in the mid-abdomen (above right). Sagittal CT (below left) shows a long length of progressive narrowing of the mid-abdominal aorta. 3D CT (below right) shows moderate stenosis of the abdominal aorta from T12 to L2 and severe ostial stenosis of the celiac artery and superior mesenteric artery and the bilateral renal arteries. The inferior mesenteric artery is enlarged with robust collaterals to the celiac and superior mesenteric circulations. There is sparing of the aortic bifurcation and iliac arteries.

The diagnosis was midaortic syndrome in a patient with neurofibromatosis Type 1.

Teenager with a cough

CXR of Kartagener syndrome — CXR AP (left) shows dextrocardia while the stomach is in the right upper quadrant. There are cystic changes in the lower lobes bilaterally which are best visualized on the CXR lateral (right).

The diagnosis was Kartagener syndrome with bronchiectasis.

Teenager with multiple long bone fractures from a motor vehicle accident who now has respiratory distress

CXR of pulmonary fat embolism — CXR AP shows diffuse nodular infiltrates throughout the lungs, right greater than left.

The diagnosis was pulmonary fat embolism.

Toddler with a murmur

CXR of pulmonary hypertension — CXR AP shows cardiomegaly with a prominent pulmonary outflow tract, enlarged pulmonary arteries, and pruning of peripheral pulmonary vessels.

The diagnosis was pulmonary hypertension.

Premature newborn with respiratory distress

CXR of congenital hypertrophic cardiomyopathy — CXR AP shows cardiomegaly with pulmonary vascular congestion. There is underlying mild ground glass opacity in the lungs as well.

The diagnosis was congenital hypertrophic cardiomyopathy and underlying respiratory distress syndrome.

Premature newborn now 1 month old with a patent ductus arteriosus

CXR of PDA clip on left mainstem bronchus — Preoperative CXR AP (above left) shows mild cardiomegaly and increased pulmonary vascularity. Postoperative CXR AP (above right) shows interval placement of a rather large clip on the ductus arteriosus. There is interval development of complete collapse of the left lung. CXR AP obtained after remove of the clip (below) shows interval reexpansion of the left lung.

The diagnosis was accidental clipping of the left mainstem bronchus along with the patent ductus arteriosus.

Teenager who was hit by a car while riding his go cart

CXR and CT of chylous pericardial effusion — CXR AP (above) shows the heart to be enlarged and to have a water bottle shape. Axial CT with contrast of the chest (below) shows a large amount of high density fluid in the pericardial space.

The diagnosis was chylous pericardial effusion due to rupture of the thoracic duct.

School ager with supraventricular tachycardia resulting in cardiac arrest

CXR of supraventricular tachycardia — CXR AP shows mild cardiomegaly with bilateral perihilar lung opacities with a batwing appearance.

The diagnosis was supraventricular tachycardia resulting in cardiogenic pulmonary edema.

Premature newborn with respiratory distress

CXR of pneumopericardium and right pulmonary interstitial emphysema which resulted in a right tension pneumothorax — CXR AP at 2 days of age (above) shows air surrounding the heart and not rising above the great vessels. Air is also present in the right pulmonary interstitium in a branching pattern from the hilum to the periphery. CXR AP at 3 days of age (below) shows air no longer surrounding the heart and interval development of a large amount of lucency in the right pleural space with mediastinal shift to the left.

The diagnosis was pneumopericardium and right pulmonary interstitial emphysema which resulted in a right tension pneumothorax.

Preschooler found face down in a pool

CXR of pulmonary edema from near drowning — CXR AP shows bilateral dense confluent infiltrates throughout the lungs.

The diagnosis was pulmonary edema from near drowning.

Preschooler with a connective tissue disease

CT of aortic dilation in Marfan syndrome — Coronal CT with contrast of the chest shows marked dilation of the aortic root and ascending aorta.

The diagnosis was Marfan syndrome.

Teenager with fever, vomiting and headache

CT of pulmonary arteriovenous malformation causing multiple brain abscesses — Axial MRI with contrast of the brain (above) shows multiple ring enhancing lesions in the cerebrum. Axial CT with contrast of the chest (below left) shows multiple necrotic mediastinal lymph nodes. Coronal CT with contrast of the chest (below right) shows a lobulated lesion in the right lower lobe with feeding and draining vessels associated with it.

The diagnosis was multiple cerebral abscesses due to a right lower lobe pulmonary arteriovenous malformation.

Infant with an omphalocele after lower extremity PICC line placement

AXR of PICC line tip misposition in the spinal canal — AXR AP (left) shows a wavy appearance to the right lower extremity PICC line. Lateral radiograph (right) shows the PICC line tip projecting over the spinal canal.

The diagnosis was peripherally inserted central catheter malfunction with the tip of the PICC line in a spinal vein.

Preschooler with abdominal pain

CT of Henoch-Schonlein purpura — Axial (above), coronal (below) and sagittal (right) CT with contrast of the abdomen shows a thickened mildly enhancing loop of proximal jejunum in the anterior midline of the abdomen. There is also a small amount of ascites present

The diagnosis was Henoch-Schonlein purpura affecting the small bowel.