A term female infant was admitted to the intensive care unit with the diagnosis of tetralogy of Fallot with critical pulmonary stenosis. On the seventh day of life a long saphenous line was inserted that remained without complications until seven days later when the infant appeared septic. A lumbar puncture demonstrated the presence of intra-lipid in the cerebrospinal fluid that we interpreted as due to migration of the saphenous catheter. The child had an uneventful recovery.
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