Caceres’ Corner Case 138 (Update: Solution)


Dear Friends,

Presenting the last case of “five easy pieces”. Images belong to a 58-year-old woman operated on for carcinoma of the rectum four months ago. She is admitted to the hospital complaining of moderate fever and abdominal pain.
What do you see?

Check the images below, leave your thoughts in the comments section, and come back on Friday for the answer.

PA chest

lateral chest

Click here for the answer to case #138

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    Apr 2016
    DISCUSSION 19 Comments

    19 Responses to : Caceres’ Corner Case 138 (Update: Solution)

    1. M. A. Fahmy says:

      There is a healed fracture of left clavicle.
      There is a line is seen extending from the right side through the subclavian vein to SVC, right atrium, IVC to the abdominal cavity ? malpositioning therapeutic line.
      there is an oval opacity is seen at the lateral X ray just anterior to the bifurcation of the trachea ? enlarged lymph node.

    2. Mohamed Amin says:

      Right hiler nodal lesion.

    3. Olena says:

      Frontal view:

      Following airways – trachea and left main bronch look normal, is there widening of right main bronch?

      Aorta contour is normal

      Both lungs are applied to the chest wall on all sides, there are some higher areated zones – symmetrically on the level of 1-2 ribs
      But the linear shadow of the minor fissure is shifted caudally – the decreased volume of right middle lobe? inferior lobe? On lateral view the major fissure is shifted dorsally – decreased volume of left inferior lobe

      Consolidated fracture of medial part of left clavicula

      Both hila: there is evidence of venous stasis – the increased vessel shadows in hilar and prehilar zones and decreased vessel architectonic on the periphery, mostly in the right side. That is why on lateral view the pulmonary arteries could mimic enlarged lymphatic nodules

      Cardiac: smooth mediastinal contours and normal shape

      Right hemidiaphragms is shifted cranially (the increased size of hepar?)

      Soft tissues show no pathology

      On the right – the shadow of catheter in vena subclavia to SVC to IVC

      On latereal view – on the level of sternum – high density shadows – suggesting calcified cartilaginous part of ribs ? were any surgical manipulations on the heart?

      There are high intensive shadows on the level of abdomen – metal clips ? probable cholecystectomy (anamnesis)?

    4. sht says:

      I agree with M. A. Fahmy.
      1. Old fracture left clavicle.
      2. Line on the right passing right through right heart into abdomen.
      3. Round hilar opacity – LN.
      4. Degenerative changes spine. Sternocostal cartilage calcification.

    5. ania says:

      anterior aspect of the second rib on the left is different than on the right.Slightly increased lucency in the first intercostal space on the left side.

    6. Eugeny says:

      Maybe I’m wrong but I think there is metastasis of the anterior part of the 3 right rib. Bone scan is required.
      The distal end of central venous catheter below the diaphragm level acceptable.

    7. Lola la Piconera says:

      Features of Cholecystectomy.
      PICC line with tip in IVC (Thrombosis?). Would need to be withdrawn and a CT depending on the time the line was placed for ruling out thrombosis.
      Bulging of the anterior outline of the ascending aorta: Aortic aneurysm? Mediastinal tumour such as a thymoma for example?

    8. genchi bari italia says:

      ….il PICC deve mantenere la sua punta alla giunzione tra atrio dx e VCS…..risulta evidente che il catetere è ” migrato” in addome….come sia giunto in quella sede sicuramente non attraverso il sistema vascolare ma per” altre” vie…fistolizzandosi …..bastererebbe iniettare del mdc e scoprire dove si posiziona la punta….Superba ripresa del Barca….non fate arrabbiare il cane che dorme !!!!

    9. Lola la Piconera says:

      I think that lines are more frequently missed and not reported in CT scans than in X Rays examination. Actually I think incluiding lines as a part of the checking list on bone when reporting window on CT scans could help.
      We are doing an Audit about PICC lines on chest Xrays and CT and at the moment the outcome is CT 0 Chest X ray 10 Champions league
      Any comment on the floor?

      • Jose Caceres says:

        Nice observation, although I find hard to believe that misplaced lines are missed more often in CT than in RX. Looking forward to the results of your audit.

    10. Rani S says:

      what’s about? is it dangerous?

      • Jose Caceres says:

        I am no expert in this subject, but I imagine it is not good for the patient and catheter should be removed as soon as possible.
        I have seen long standing misplaced catheters causing venous thrombosis. I believe perforation of the vein is also a possibility.