Presentation
Extremely low birth weight and prematurity at 26 weeks gestation with respiratory distress and now septicemia.
Patient Data
There is surfactant deficiency disorder with right lower lobe consolidation. The trachea is central. The cardiothoracic ratio is normal. The nasogastric tube has been satisfactorily sited.
The right upper limb peripherally inserted central catheter (PICC) is malpositioned and infra-diaphragmatic with the tip at approximately L1/L2 vertebral body level.
There is intrahepatic portal venous gas. The lateral shoot-through confirms pneumatosis intestinalis. The features suggest necrotizing enterocolitis in a markedly premature neonate.
There is no pneumoperitoneum.
Case Discussion
A case of a malpositioned PICC. In this instance, the portable X-rays were performed within 20 minutes of insertion of the PICC and there is clinical confirmation of the absence of any TPN or hypertonic saline infusion before this X-ray is performed. This excluded a TPNoma or catheter-related intrahepatic fluid collection/ abscess.
The presence of exogenous gas within the portal veins is always possible when UVC and PICCs are malpositioned. In this instance, the intrahepatic portal venous gas is more ominous and due to the necrotizing enterocolitis that has occurred in this markedly premature infant. This was confirmed by the presence of pneumatosis intestinalis, a septic clinical and biochemical scenario with clinical deterioration at day 7.
The neonate had a previous UVC, UAC and ETT. There was subsequent re-intubation post this X-ray findings.
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