Abscess formation following secondary migration of peripherally inserted central catheter in a neonate: a case report and review of literature

Abstract

Introduction:

Peripherally inserted central catheters (PICCs) are widely used for long-term intravenous access in neonatal intensive care units (NICUs). Although generally safe, PICC-related complications can occasionally be serious. Abscess formation is a rare but significant event. This report describes a preterm neonate who developed a left flank abscess secondary to PICC line migration, emphasizing the importance of meticulous monitoring of catheter position and related complications.

Case presentation:

A preterm twin neonate born at 32 weeks was admitted to the NICU with respiratory distress syndrome. A PICC line was placed for parenteral therapy. On day 30, the infant developed lethargy and feeding intolerance, and sepsis work-up revealed infection. Despite antibiotic therapy, a warm, erythematous swelling appeared on the left flank. Imaging showed a large abscess with an air-fluid level, with the PICC tip located within the collection. The infant received Linezolid and Colistin, followed by surgical drainage, which yielded pus. Clinical improvement ensued and the neonate was discharged after completing antibiotic therapy. Follow-up imaging confirmed complete resolution.

Discussion:

PICC complications include secondary migration – reported in 4–12% of cases – which may lead to severe infections. In this case, secondary migration likely caused abscess formation, despite correct initial placement.

Conclusion:

This case highlights that even when initially positioned correctly, PICCs require continuous monitoring to detect potential migration and associated complications. Enhanced awareness, routine imaging reassessment, and standardized follow-up protocols can improve safety and outcomes in neonatal PICC management.

Introduction

Peripherally inserted central catheters (PICCs) are commonly used for various purposes and offer advantages such as cost-effectiveness, safety, and preference over centrally inserted central catheters^[1^]. In neonatal intensive care units (NICUs), ensuring secure intravenous access is crucial for delivering medications, fluids, nutrition, blood, and blood products^[2^]. PICC-related complications include bacteremia, phlebitis, migration and malposition, effusion, thrombosis, phrenic nerve injury, and extravasation^[3^]. Although rare, abscess formation is a known complication of PICC placement. In this case report, we present a neonate who developed an abscess following PICC insertion. This case report has been reported in line with the SCARE checklist^[4^].

HIGHLIGHTS

• A rare case of neonatal flank abscess caused by secondary peripherally inserted central catheter (PICC) migration.

• Abscess developed despite correct initial PICC placement.

• Secondary PICC migration resulted in deep soft-tissue infection.

• CT imaging identified PICC tip malposition within the abscess.

• Continuous monitoring of PICC position is essential in preterm neonates.

Case presentation

The patient was a neonate who developed a left flank abscess on the 30th day of life. He was born at 32 weeks gestation via cesarean section due to preterm labor in a primigravid mother with a twin pregnancy. His birth weight, head circumference, and length were 1340 g, 29 cm, and 40 cm, respectively. The Apgar score at 1 and 5 minutes after birth was 8 and 9, respectively. The pregnancy course was uneventful except for the preterm labor that led to the delivery, and the mother had no history of infection during pregnancy. Sonographies throughout pregnancy revealed a dichorionic diamniotic twin pregnancy with a normal amount of amniotic fluid and no detected anomalies. There was no relevant family history except for the mother^’s major thalassemia. He was admitted to NICU due to prematurity and respiratory distress syndrome and a PICC line was inserted on 2nd day of life through the femoral vein. It was placed according to our standard neonatal protocol. The procedure was conducted under full sterile conditions, including skin preparation with 2% chlorhexidine, sterile draping, and the use of sterile gloves and instruments. A Vygon single-lumen polyurethane PICC (2 Fr) was used. Venous access was obtained using a modified Seldinger technique: the selected left femoral vein was punctured with a small-gauge introducer needle, a guidewire was advanced, and the catheter was inserted to the pre-estimated length based on external anthropometric measurement. Catheter tip position was confirmed by radiography and adjusted when necessary.

Cardiorespiratory monitoring was maintained throughout the procedure. After insertion, the catheter was secured with a sterile adhesive dressing, and patency was confirmed by blood aspiration and saline flushing.

The procedure was performed under sterile conditions, using sterile drapes and equipment. After insertion, the correct placement of the catheter was confirmed via radiography. The catheter was secured with adhesive tape to prevent movement and dislodgement. On day 22, he developed lethargy and intolerance to feeding. Sepsis work-ups revealed leukocytosis, elevated C-reactive protein (CRP) (44 mg/l), mixed bacteria in urine culture, and Staphylococcus aureus in cerebrospinal fluid culture. The blood culture showed no microorganisms. He was treated with broad-spectrum antibiotics (vancomycin 15 mg/kg/dose q8h, meropenem 40 mg/kg/dose q8h) based on antibiogram. On day 30, a warm erythematous mass on his left flank began to enlarge progressively (Fig. 1) with redness, hotness, and induration.

Figure 1.

Warm erythematous mass that enlarged progressively.

Despite the broad-spectrum antibiotic treatment, his CRP remained elevated (above 100 mg/l). The differential diagnoses included hematoma, soft tissue swelling, and abscess formation. To establish a definitive diagnosis and guide appropriate treatment, imaging studies were requested. Sonography could not distinguish between an abscess and a hematoma. Computed tomography (Fig. 2) showed a large collection with an air-fluid level in the left flank and a catheter in the left abdominal cavity, identified as the tip of the PICC line, which was subsequently removed.

Figure 2.

Axial (A), coronal (B), and sagittal (C) images of abdominopelvic enhanced CT scan shows; left side retroperitoneum collection with extension to sub cutaneous posterior abdominal wall due to migration of tip of PICC.

His antibiotics were changed to Linezolid (10 mg/kg/dose q8h) and Colistin (4 mg/kg/day) following an infectious disease consultation for 10 days. After preparation and draping, and under anesthesia in the supine position, a cruciate incision was made over the point of maximum bulging. Approximately 50 cc of pus was drained, followed by thorough irrigation. The wound was left open and a dressing was applied. His condition improved after the drainage and his CRP normalized. He was discharged after completing the antibiotic course and clearing all cultures. His follow-up sonography showed no residual collection. At the 2-month follow-up, he demonstrated normal growth indices and development, with no complaints.

Discussion

The PICC is a commonly used, long and flexible catheter made of silicone or polyurethane, which is inserted through a peripheral vein and advanced to reach a central vein^[5^]. It provides a safe widely utilized method of intravenous access, with the ability to remain in place for weeks or even months. PICCs generally pose fewer serious risks^[6^].

This case is notable for the development of a large flank abscess in a preterm infant and the diagnostic delay caused by vague early symptoms despite ongoing antibiotic therapy. The combination of persistent sepsis markers, late localized swelling, and the need for cross-sectional imaging to establish the diagnosis underscores that PICC-related complications may evolve insidiously and present outside the typical early post-insertion period. This highlights the importance of reconsidering catheter position and function whenever clinical improvement fails to occur, even when the initial placement had been confirmed radiographically.

PICC-related complications in neonates are multifactorial and encompass infectious, mechanical, and vascular issues. Infectious events include catheter-related bloodstream infections as well as localized catheter-site inflammation and phlebitis^[7,8^]. Mechanical and insertion-related complications range from catheter occlusion, malposition, migration, accidental dislodgement, and rupture to extravasation, particularly when the tip is incorrectly positioned or the vessel is compromised^[9,10^]. Vascular complications such as thrombophlebitis, deep vein thrombosis, and limb edema or impaired perfusion may also occur, especially in preterm infants with fragile vasculature^[7,11^]. Although rare, life-threatening complications – including cardiac tamponade, pleural effusion, pneumothorax, and chemical pneumonitis^[10,12^] – underscore the importance of precise tip placement, strict aseptic technique, and vigilant monitoring throughout catheter use in neonatal intensive care.

The position of the PICC tip is crucial and typically placed near the heart or within the superior or inferior vena cava. Radiography is commonly employed to verify the catheter tip’s location^[13^]. Although a clear association between the PICC tip location and complications exists, the clinical significance of the tip position remains a subject of an ongoing debate^[14^]. One of the complications related to the PICC usage is secondary migration, which is defined as a change in the catheter tip’s position after initial confirmation through imaging^[15^]. The reported incidence of secondary migration of PICC is 4–12%^[8,16^]. In our patient, despite the initial confirmation of proper placement through radiography, secondary migration occurred, resulting in complications with abscess formation.

The risk factors for secondary PICC migration are not well understood. Previous studies suggest that difficult insertion and dressing changes may be associated with catheter migration^[9^]. Additionally, changes in body position and movement, such as limb extension and flexion, could contribute^[9,17^]. The site of insertion appears to be insignificant in influencing migration^[9^]. In our case, changes in position and dressing may have been contributing factors. The prolonged duration of the PICC line, which had been in place since the second day of life, may have also played a role.

Abscess formation is a rare but serious complication associated with central venous catheters. There are few case reports describing liver abscess and intra-abdominal free fluid accumulation in preterm infants due to an umbilical line malposition^[18,19^]. Similarly, abscess formation has been observed in neonates with PICC lines. Govind et al reported a case of preterm infant with a mispositioned PICC line leading to extravasation of total parenteral nutrition and swelling in the right infraclavicular region^[20^]. Garg et al also reported a preterm neonate who was operated due to necrotizing enterocolitis. A PICC line was inserted after operation, and the position was checked with radiography. The abdomen over the iliac fossa became tense, erythematous, and distended. Abscess drainage was clear without any organisms but the oozing continued. Malposition and extravasation of the PICC line were diagnosed, and she improved after the removal of the PICC line^[21^].

Based on our case and the available literature, several practical recommendations may help clinicians reduce the risk of PICC-related complications in newborns. Careful selection of the insertion site and use of ultrasound guidance, when available, can improve cannulation success and reduce malposition. An accurate estimation of the catheter length and a mandatory post-insertion radiographic confirmation remain essential, particularly in preterm infants with a variable anatomy. Continuous clinical surveillance – including a routine inspection of the insertion site, close monitoring for limb edema, erythema, or unexplained abdominal or thoracic swelling, and a prompt evaluation of any change in the catheter function – facilitates early recognition of complications such as extravasation or abscess formation.

This case report’s strength lies in highlighting a rare PICC-related abscess in a preterm neonate with detailed clinical and imaging documentation, offering practical preventive insights. Its limitations include being a single case with limited generalizability.

Further studies are needed to better understand the risk factors for PICC migration and to improve monitoring protocols for patients with PICCs.

Conclusion

In conclusion, although secondary migration of PICCs is rare and often asymptomatic, it should be carefully considered during the interpretation of any radiographic study. Vigilance for associated complications such as abscess formation is essential, particularly in preterm neonates with fragile vasculature. This case underscores the importance of meticulous tip confirmation, routine reassessment when clinical signs change, and prompt evaluation of catheter function to enhance patient safety and optimize clinical outcomes in neonatal PICC management.

Ethical approval

This study was approved by the Ethics Committee of Shiraz University of Medical Sciences, Shiraz, Iran (Ethical approval ID: IR.SUMS.REC.1402.397).

Consent

A written informed consent was obtained from the patient’s legal guardian for publication of this case report and any accompanying images. A copy of the written consent is available for review from the Editor-in-Chief of this journal.

Sources of funding

This case report received no funding.

Author contributions

F.H., S.M.R., R.O., and H.B. had roles in treating the patient and gathering information. F.Y. had performed the radiologic reports. All authors had contribution in writing and editing the final manuscript. All authors read and approved the final manuscript.

Conflicts of interest disclosure

None.

Research registration unique identifying number (UIN)

Name of the registry: Shiraz University of Medical Sciences. Unique identifying number or registration ID: 29111. Hyperlink to your specific registration (must be publicly accessible and will be checked): https://rpis.research.ac.ir/Index.php?id=555638

Guarantor

Hamide Barzegar.

Provenance and peer review

Not commissioned; externally peer-reviewed.

Data availability statement

Materials and data provided in this case study are available from the corresponding author on reasonable request.