Hidden danger: Unrecognized intrathoracic placement of a central venous catheter despite an initially...

Although a routine and generally safe procedure, central venous catheter insertion has inherent risks, which can be mitigated with the use of imaging studies. This case report describes the unrecognized intrathoracic placement of a central venous catheter in a 15-year-old female with a history of anorexia nervosa. A chest radiograph obtained immediately after the procedure appeared normal at the time, but retrospective review revealed a subtle right-sided pneumothorax. Subsequent computed tomography demonstrated that the catheter had perforated the right internal jugular vein and entered the thoracic cavity. The case highlights the limitations of relying solely on chest radiography for central venous catheter placement confirmation, the potential for missed subtle complications, and emphasizes the importance of clinical vigilance and additional imaging when catheter malposition is suspected.