X-Ray of One-Sided “White Lung” after Central Venous Catheterization

Complications during insertion of a subclavian central venous line are rare but potentially serious. This case report describes the radiological abnormality of a one-sided pleural effusion during a routine control directly after a difficult central venous catheterization. We illustrate the findings, the initial emergency management, and our procedure to rule out an iatrogenic hemothorax. Possible differential diagnoses and strategies for management of a suspected complication are discussed. 1. Introduction For patients in the United States, as many as five million central venous lines are placed annually. Perforation of the subclavian artery occurs in about 0.1–1% of cases, leading to hemothorax (1%) and rarely quadriplegia. Perforation of the aorta and cardiac tamponade can occur if the cannula-site perforation is within the pericardial reflection. This complication is associated with a death rate of 90% [1, 2]. Compulsory radiological control of central venous access is debated but is still routinely performed in our institution. 2. Case Description An 88-year-old woman was initially admitted for correction of poorly controlled diabetes mellitus. During her hospitalization, she developed peripheral catheter-associated Staphylococcus aureus thrombophlebitis in her left cubital region. The patient was on IV antibiotics for four days. Initially, trimethoprim/sulfamethoxazole had been used. After 2 days, this was followed by ceftriaxone due to antibiotic resistance. After deciding on long-term antibiotic treatment with IV cefazolin and due to bad peripheral venous conditions, the patient was scheduled for central venous catheterization. Relevant diagnoses of the patient were (i) known hypertensive cardiac disease (transthoracic echocardiography 6 months before had shown a LV-EF of 54% and a light mitral and tricuspid insufficiency) and (ii) liver cirrhosis with portal hypertension. A recent CT scan showed signs of liver cirrhosis with ascites and splenomegaly, and abdominal sonography 2 months ago supposed the findings to be due to a steatohepatitis. Liver serologies were negative for a lack or deficiency of alpha-1 antitrypsin. Ceruloplasmin and alpha-fetoprotein were normal. No signs of active viral hepatitis were found, and the patient’s carcinoembryonic antigen value was within the normal range. Finally, cytological screens of the ascites showed no signs of malignancy. Besides the antibiotics, medical therapy at the time of consultation included torsemide, spironolactone, and sitagliptin. Laboratory examination revealed thrombocytopenia (78,000/μL)