Welcome to the sixth season of Cáceres’ Corner. I will present cases during the month of September because Dr. Pepe is vacationing in Menorca with Miss Piggy and will not start the Diploma cases until October.
My close friend Larry Goodman, Director of Chest Imaging at the Medical College of Wisconsin, provides the first case. The images are of a 27-year-old male who was shot in the abdomen. I am showing chest radiographs taken on admission and after a CT was performed.
Check the images below, leave your thoughts in the comments section, and come back on Friday for the answer.
The main finding in the admission chest is a bullet overlying the cardiac shadow (A, arrow). A second chest radiograph after CT shows the bullet in the right upper quadrant of the abdomen (B, arrow). Considering that the patient was shot in the abdomen, it is obvious that the bullet has travelled from the abdomen to the chest and returned to the abdomen
I have received ingenious suggestions regarding the possible paths of the travelling bullet, but the most credible one is that it is travelling through the blood vessels. This is confirmed by CT images, which show the bullet in the right ventricle (C, arrow) and a few seconds later in the IVC (D, arrow).
The most likely path is then: departing from the IVC (1), the bullet reaches the RV (2) and then follows a retrograde path to the IVC again (3) as shown below. An alternative explanation would be an intracardiac shunt or a pulmonary AV fistula, but there is no evidence to support this hypothesis.
The patient had a laparotomy where several internal injuries were repaired including a rent in the inferior vena cava. No bullet was found.
Wandering bullets have been reported previously. In Spain we are more primitive and use shotguns. Radiographs below show a patient shot in the shoulder. A single pellet has emigrated through the veins to the RV (A-B, arrows).
Congratulations to all of you, because it was a hard case. Olena was the first to mention the vascular route and TR brilliantly summarized it.
Teaching point: this is an unusual case and brings to mind the words of Sherlock Holmes: “Once you eliminate the impossible, whatever remains, no matter how improbable, must be the truth”.
