Sclerotic bone pseudolesions - external artifact

Case contributed by Daniel J Bell
Diagnosis certain


Check radiograph following central venous line insertion. ICU patient with severe pneumonia and sepsis.

Patient Data

Age: 65 years
Gender: Female

Mobile AP erect (ICU image)


Suboptimal image: lung bases cut off. 

Right-sided IJV catheter in reasonable position. Right-sided chest drain with the tip projected over the lateral mid zone. Cardiac monitor leads. 

Right-sided pleural effusion with lamellar and fissural components. Right lower lobe pneumonia. 

Suspicion of sclerotic lesions of the right humeral head and glenoid process.

2 days later (ICU image)


Sclerotic lesions of the right humeral head no longer seen.

Worsening consolidative lung changes.

Case Discussion

The so-called sclerotic lesions of the right humerus are artifactual. Closer inspection of the original radiograph shows that one of the "lesions" slightly extends laterally to the humeral cortex. Another lesion apparently lies in the glenoid process. The morphology of all the "lesions" is also strikingly similar and tubular densities are also present a little more superiorly in close proximity.

The presence of the superimposed "AP Semi-erect Mobile" label is unhelpful here, obscuring the underlying structures. Although to be fair to the radiographer, the label positioning is outside the area of interest (i.e. position of the right IJV catheter) and it has to be put on the image somewhere! These positioning labels are digitally 'burnt-into' the image and remain even after other annotations are removed.

In actuality, the lesions represent injection ports for the central venous catheter projected over the right shoulder; hence their apparent absence two days later.

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