Premature newborn after PICC line placement

CXR of PICC line in the left pulmonary artery — CXR AP shows a left upper extremity PICC line whose tip projects over the left pulmonary artery.

The diagnosis was peripherally inserted central catheter malposition in the left pulmonary artery.

Teenager with malignant hypertension and an abdominal bruit

CT of midaortic syndrome and bilateral renal artery stenosis — 3D CT angiogram with contrast of the abdomen shows diffuse narrowing of the mid abdominal aorta and marked narrowing of the origins of the bilateral renal arteries.

The diagnosis was midaortic syndrome with bilateral renal artery stenosis.

Premature newborn after PICC line placement

AXR of PICC line in left gonadal vein — AXR AP shows a right lower extremity PICC line whose tip projects over the scrotum, presumably in the left gonadal vein.

The diagnosis was peripherally inserted central catheter malposition with the tip in the left gonadal vein.

Newborn with cardiomegaly on prenatal ultrasound

CXR of congenital dilated cardiomyopathy — CXR AP shows cardiomegaly with normal pulmonary vascularity. The umbilical venous catheter tip projects over the right atrium.

The diagnosis was congenital dilated cardiomyopathy with high malposition of the umbilical venous catheter.

Premature newborn after umbilical arterial catheter placement

AXR of umbilical arterial catheter malposition in external iliac artery — AXR AP shows an umbilical arterial catheter whose tip projects inferiorly over the left external iliac artery. The tip of the umbilical venous catheter is at the cavo-atrial junction.

The diagnosis was umbilical arterial catheter malfunction with malposition of the tip in the left external iliac artery.

Teenager who is short of breath who is a smoker, on oral contraceptives, and has a large body mass index

CT of bilateral pulmonary embolus — Axial (above) and coronal (below) CT with contrast of the chest shows large and lengthy low density intraluminal filling defects in the left and right pulmonary arteries.

The diagnosis was bilateral pulmonary embolism.

Preschooler post renal transplant whose central venous catheter will not draw back

Fluoroscopic exam of fibrin sheath on central venous catheter — AP image from a central venous catheter injection shows widening of the diameter of the distal end of the catheter. Contrast did not flow out of the tip of the catheter but instead flowed out of the catheter in a more superior location, at approximately the level where the catheter enters the superior vena cava, where a linear collection of contrast can be seen to the right of the catheter.

The diagnosis was central venous catheter malfunction due to a fibrin sheath at the tip of the catheter.

Newborn with hypoxia

CXR of Ebstein anomaly — CXR AP shows an extremely enlarged (wall to wall) heart and decreased pulmonary vascularity.

The diagnosis was Ebstein anomaly.

Preschooler with a central venous catheter that will no longer draw back

CXR of central venous catheter fracture — CXR AP when the catheter was placed one year ago (left) shows the tip of the catheter at the cavoatrial junction in correct position. CXR AP today (right) shows the catheter is now fractured and discontinuous and has embolized into the right atrium.

The diagnosis was central venous catheter fracture.

Teenager who had thoracic surgery a week ago and now has sepsis

MRI of infective endocarditis of the brain and CT of infective endocarditis of the spleen and kidneys — Coronal T1 MRI with contrast of the brain (above) shows multiple small enhancing lesions in the brain and one large ring enhancing lesion in the right hemisphere of the brain. Coronal CT with contrast of the abdomen (below) shows multiple peripheral low density wedge shaped lesions in the spleen and both kidneys.

The diagnosis was infective endocarditis leading to cerebral abscess and splenic abscess and renal abscess.

Newborn with increasing respiratory distress after subclavian venous catheter placement for total parenteral nutrition (TPN) 2 days ago

CXR of pericardial effusion due to malposition of central line in the pericardial space — CXR AP (left) shows the tip of the newly placed left subclavian venous catheter to project deep within the right atrium while the cardiac silhouette is normal in size. CXR AP 2 days later (right) shows the catheter tip unchanged in position while the cardiac silhouette has increased markedly in size in the interval. Cardiocentesis returned TPN.

The diagnosis was subclavian venous catheter malposition in the pericardial space resulting in a pericardial effusion and cardiac tamponade.

Newborn with respiratory distress

CT of cardiac rhabdomyoma — CXR AP (above left) shows cardiomegaly. Coronal CT with contrast of the chest (above right) shows a large low density nonenhancing mass inside the heart which on axial CT (below left) appears to be in the right ventricle and on sagittal CT (below right) appears to be encroaching on the right ventricular outflow tract.

The diagnosis was cardiac rhabdomyoma in a patient with tuberous sclerosis.

Premature newborn with hepatomegaly and an elevated white blood cell count after umbilical venous catheter malposition

US of TPNoma — Initial AXR AP (above left) shows the umbilical venous catheter (UVC) tip to project over the liver and not to project at the junction of the inferior vena cava and right atrium. The UVC did not work well and was removed several days later. AXR 2 weeks later (above right) shows interval development of hepatomegaly. Transverse (below left) and sagittal (below right) US of the liver show a large septated and complex fluid collection within the liver.

The diagnosis was an infected TPNoma due to umbilical venous catheter malposition.

Toddler with a murmur

CXR and angiogram of valvular pulmonary stenosis — CXR AP (left) shows prominence of the main pulmonary artery. AP image from a right ventricular injection of an angiogram (above right) shows a dilated main pulmonary artery while the lateral (below right) from the same injection shows doming of the pulmonary valve and a narrow jet of contrast entering the dilated main pulmonary artery.

The diagnosis was pulmonary stenosis at the level of the pulmonary valve.

Toddler with respiratory distress and a cardiac murmur

CXR of left pulmonary artery stenosis — CXR AP shows markedly decreased pulmonary vascularity in the left lung when compared to the right lung. The lungs are clear.

The diagnosis was peripheral pulmonary stenosis due to left pulmonary artery stenosis.

Teenager with a murmur

CXR of aortic stenosis — CXR PA shows mild dilation of the ascending aorta.

The diagnosis was aortic stenosis.

School ager with osteomyelitis of the left lower extremity

CXR and CT of pulmonary arterial aneurysm — CXR PA (above left) shows a large, round lesion projecting to the right of the heart while the lateral (above right) shows it to be located posteriorly in the chest. Coronal (below left) and axial (below right) CT with contrast of the chest shows the distal right main pulmonary artery to be aneurysmally dilated.

The diagnosis was right pulmonary arterial aneurysm.

Teenager with dysphagia

CT of right aortic arch without an aberrant vessel — Coronal CT with contrast of the chest (below) shows a right aortic arch with mirror image branching of the great vessels arising from it. Axial CT (above) shows a functional vascular ring with the trachea and esophagus going through the center of it.

The diagnosis was right aortic arch without an aberrant vessel.

Toddler with shortness of breath and abnormal cardiac rhythm

CXR of ventricular tachycardia — CXR AP shows cardiomegaly, pulmonary vascular congestion, and small bilateral pleural effusions.

The diagnosis was ventricular tachycardia.

Teenager with shortness of breath after motor vehicle accident

CT of pulmonary fat embolism — AP radiograph of the right femur (left) and lateral radiograph of the right tibia and fibula (middle) show comminuted fractures of the femur, tibia, and fibula. Axial (above right and middle right) and coronal (below right) CT with contrast of the chest shows a geographic distribution of ground glass opacities throughout both lungs.

The diagnosis was pulmonary fat embolism.

Newborn with abnormal prenatal cardiac ultrasound

CXR and CT of main pulmonary arterial aneurysm due to absent pulmonary valve syndrome — CXR AP (above) shows an abnormal and prominent contour to the left superior mediastinum. The right superior mediastinum contour represents the thymus. Coronal CT with contrast of the chest (below) shows aneurysmal dilation of the main pulmonary artery. The pulmonary valve was absent.

The diagnosis was main pulmonary arterial aneurysm due to absent pulmonary valve syndrome.

Teenager with black and blue subcutaneous nodules and chronic GI bleeding

Tagged red blood cell nuclear medicine scan and angiogram of blue rubber bleb nevus syndrome — Nuclear medicine tagged red blood cell scan for GI bleeding shows AP and lateral images of the abdomen obtained immediately after the beginning of the exam (above top row) and 4 hours later (above bottom row). The images show immediate pooling of radiotracer in multiple discrete areas in the abdomen and pelvis with continued radiotracer accumulation in these areas over time. Arterial phase image from a superior mesenteric artery angiogram (below left) shows normal arterial vessels, while the venous phase (below right) shows contrast puddling in rounded spaces that filled in over time in the small bowel and ascending colon that were consistent with venous malformations.

The diagnosis was blue rubber bleb nevus syndrome.

Preschooler with an arrhythmia

CXR of broken cardiac pacemaker leads — CXR AP (left) shows short lucent areas in the lateral aspect of the third and fourth pacemaker leads. Repeat CXR AP 1 month later (right) shows a complete discontinuity of the third pacemaker lead and elongation of the lucent area in the lateral aspect of the fourth pacemaker lead.

The diagnosis was cardiac pacemaker lead malfunction in the form of developing fractures in the pacemaker leads.

Premature newborn with new left femoral vein catheter that will not infuse

Venogram of perforation of femoral venous catheter out of the femoral vein — AXR AP (left) shows a left femoral venous catheter whose tip projects to the left of the L5 vertebral body, rather than projecting near the middle of the L5 vertebral body. AP venogram taken after injecting contrast through the femoral catheter (right) shows extravasation of contrast into the soft tissues surrounding the catheter tip.

The diagnosis was femoral venous catheter malfunction with perforation of the femoral venous catheter out of the femoral vein.

Infant with a femoral line that does not infuse

Line study showing thrombosis of a femoral venous catheter — AXR lateral (above) shows the tip of the left femoral venous catheter to be in the inferior vena cava. AP (below left) and lateral (below right) images after injection of the catheter show contrast opacifying a long non-occlusive thrombus in the inferior vena cava from the T10-L1 vertebral bodies.

The diagnosis was femoral venous catheter malfunction due to catheter tip thrombosis.