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Central line complication…

April 14, 2014

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Central line mishap 1

Central line mishap 2 Central line mishap 3 Central line mishap 4

Central lines are often necessary and performed quite frequently.  With frequent procedures sometimes we get comfortable performing them and we minimize possible dangers.  This case demonstrates, however, that there are real complications that can occur from our invasive procedures.  Thus it is important to weigh the risks and benefits.

This central line decided to go through the caudal portion of the brachiocephalic vein and into the mediastinum.  The first xray shows the end of the catheter kinked near the aortic root.  CT of the chest shows the distal tip of the catheter puncturing through the vein and into the mediastinum.  Obviously this is a very rare complication!

Image Contributor:  Aaron Hougham, MD

Author:  Russell Jones, MD


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Multiple masses chest..

April 3, 2014


Late 20s male presents with shortness of breath…

Chest masses Chest masses CT

This Xray and CT show a phenomena called “Cannonball Metastases.”  This refers to innumerable descreet masses in the chest.  Two tumors are highly suspected in this case: renal cell carcinoma and choriocarcinoma.   Others that have a higher prediliction to multiple lung mets are prostate, endometrial, and synovial sarcoma (1). 

This patient ended up having a choriocarcinoma of the testes. 

Image Contributors:  Kevin Murphy, MD and Mary Bing, MD

Author:  Russell Jones, MD


1.  Knipe H, Bickle I, et al.  Cannonball Metastases.

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Heart in the Heart…Happy Valentine’s Day

February 14, 2014


This patient had a transvenous pacemaker placed for severe bradycardia:

Heart in heart


This patient has a transvenous pacing wire which decided to loop around the right side of the heart.  It was working though!  Happy Valentine’s Day.

Image contributor:  James Chenoweth, MD

Author:  Russell Jones, MD

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Stabbed in the chest…

January 29, 2014


This patient was stabbed in the chest multiple times.  Markers showing the external stab wounds to the lateral chest wall on the right side:

HemoPTX stabbed

This is a classic trauma chest xray with a hemopneumothorax on the right side.  This patient has a great indication for a large-bore chest tube!  Not only to reexpand his lung but to monitor hemothorax output and need for emergent thoracotomy to evaluate the source of bleeding.  Trauma recommendations from the Journal of Trauma in 2010 concerning hemothorax include:

1.  Patient physiology should be the primary indication for surgical intervention rather than absolute numbers of initial or persistent {chest tube} output (Level I recommendation)

2.  1500 ml via a chest tube in any 24-hour period regardless of mechanism should prompt consideration for surgical exploration (Level II recommendation)

3.  All hemothoracies, regardless of size, should be considered for drainage (Level III recommendation)

Please see the EAST Trauma Guidelines for further details:

Mowery NT, et. al.  Practice Management Guidelines for Management of Hemothorax and Occult Pneumothorax.  J Trauma 2011; 70 (2): 2011. 

Author:  Russell Jones, MD

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Answer: Can you find the abnormalities?

December 2, 2013


I gave you this xray a couple days ago, can you find all the abnormalities?


1.  Intubated into the right mainstem bronchus

2.  Metallic foreign bodies coursing up the left chest to the neck

3.  Completely opacified left lung:  differential diagnosis of pulmonary contusion, hemothorax, or complete atelectasis from right mainstem intubation

4.  There is a chest tube in the right chest cavity, it looks to be in good position but could be coursing into the fissure between the left lobes

5.  Deep sulcus sign on the left side indicates possible pneumothorax vs. hemothorax

6.  Orogastric tube courses below the diaphragm in good position

7.  Subcutaneous emphysema in upper neck

8.  Two radiodense objects in the midline cardiac silhouette near the mid-portion of the coursing orogastric tube

Interestingly, this patient was shot in the chest coursing to the upper neck and the bullet was found in his posterior pharnyx.  He had a tooth found on chest CT (calcified opacity seen below) among other injuries.   Later EGD intraoperatively showed two tooth fragments in the stomach.  The radiodensities seen #8 above were presumed to be these teeth in the esophagus.


Image Contributor:  Julie Phan, MD

Author:  Russell Jones, MD

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Can you find all the abnormalities?

November 28, 2013


This patient came in after a reported gunshot wound.  Can you find all the abnormalities in this xray?



Answer to follow.

Image Contributor:  Julie Phan, MD

Author:  Russell Jones, MD

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19 month old with pneumonia…

November 3, 2013


Peds PNA

This is an interesting pediatric chest Xray.  Immediately you notice that the right lung is diffusely more dense than the left.  This is because the patient is supine and a pleural effusion is layering behind the right lung in a dependent fashion.  Also notice the hyperinflation of the left side compared to the right.  This patient ended up having a post-obstructive pneumonia due to aspiration!

Author:  Russell Jones, MD

Image Contributor:  Kendra Grether-Jones, MD

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What is this device?

October 26, 2013


What is this device?


This patient has two devices on Chest Xray and KUB:

1.  The large, radiodense structure just below the cardiac silhouette is a Left Ventricular Assist Device (LVAD).  Specifically it is a Heartmate II®.  LVADs are implanted in patients with severe cardiac depression for augmented left ventricular output.  Often these are implanted in patients awaiting cardiac transplant, however we are seeing more patients with implanted LVADs for “Destination Therapy.”  This is a long-term treatment for severe CHF with no intention of eventual cardiac transplantation.   The goal of these devices is to improve quality-of-life in severe CHF.  Complications most-often include thrombotic (ischemic stroke) or hemorrhagic (patients require anticoagulation with these devices which predisposes them to GI, CNS, other hemorrhagic events). 

2.  He has an Automatic Implantable Cardiverter Defibrillator (AICD) in the left upper chest.  It also functions as a pacemaker. 

A word of warning:  some of these patients will not have pulses because these devices provide a continuous left ventricular output.  A good way to obtain a blood pressure is to manually inflate the blood pressure cuff with a doppler transducer on the radial artery, as you release the blood pressure cuff you will obtain a doppler signal at some point.  This is your blood pressure (a single number).  Often they will have pulsatile flow if the intrinsic function of the heart provides enough stroke volume on top of the LVAD. 

Author:  Russell Jones, MD

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Answer AIDS PNA…

October 22, 2013


On a previous post I posed a question on the differential diagnosis of pneumonia in an AIDS patient with this chest Xray:


This is a multilobar pneumonia vs. ARDS (Acute Respiratory Distress Syndrome).  AIDS patients can have the same bacterial causes of multilobar pneumonia that is present in other patient populations (Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus Influenza, Moraxella catarrhalis, Mycoplasma pneumoniae, Chlamydophila pneumoniae, Legionella pneumoniae, etc.).  If they are healthcare associated or hospital-acquired further drug-resistant bugs such as Pseudomonas aeruginosa and MRSA could be implicated.  Infectious organisms specifically involved in immunocompromised hosts could include (among others):

  • Pneumocystis Jiroveci (PCP pneumonia)
  • Coccidioides species
  • Cytomegalovirus (CMV)
  • Tuberculosis (TB)
  • Histoplasma species
  • Aspergillus species
  • Mycobacterium avium complex (MAC)
  • Influenza
  • Herpes simplex virus (HSV)
  • Varicella-zoster virus (VZV)
  • Legionella species
  • Nocardia species
  • Cryptococcus neoformans
  • Mucoraceae species
  • Strongyloides species
  • Toxoplasma species
  • Capnocytophaga species

Non-infectious causes of multilobar infiltrates such as this could include diffuse alveolar hemorrhage, cardiogenic pulmonary edema, ARDS, among others. The multilobar involvement of the Xray above could implicate certain pathogens in favor of others (for example, Pneumocystis Jiroveci is usually multilobar as opposed to Streptococcus pneumonia which usually will cause a dense, lobar pneumonia).  The other interesting feature of the Xray is that it appears multi-nodular.  This can implicate entities such as CMV rather than a bat-wing ground-glass appearance of Pneumocystis Jiroveci.  For further discussion on pneumonia radiographic findings in AIDS, please see discussion below:

Incidentally, the endotracheal tube should be pulled back about 2 cm.

Author:  Russell Jones, MD


1.  Jones J, Stanislavski A, et al.  Pulmonary Manifestations of HIV/AIDS.  Accessed 10/2013.

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COPD and dyspnea…

October 18, 2013


This patient has a history of COPD (Chronic Obstructive Pulmonary Disease) and presented with acute shortness of breath:


One of the complications of COPD are pulmonary bullae.  Bullae are thin-walled, air-filled spaces that enlarge over months to years.  Sometimes they can burst, causing pneumothoracies.  This Xray demonstrates a pneumothorax on the left side in which a chest tube was placed for reexpansion.  On the right side the patient has multiple large apical bullae which are also at risk of rupture.  The chest tube is in good position with the side-port visualized inside the thoracic cavity and reexpansion of the lung is demonstrated.

Author:  Russell Jones, MD

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