• A 9-month-old male infant, born at 32 weeks' gestation, had neonatal necrotizing enterocolitis and required long-term parenteral nutrition. At 9 months of age, a central venous catheter was inserted through the left saphenous vein into the inferior vena cava, and the infant died nine days later. Shortly before death, a lumbar puncture yielded milky fluid with an extremely high glucose and protein content. A postmortem barium injection through the central catheter demonstrated free barium in the retroperitoneal cavity and epidural space, and autopsy findings confirmed that the catheter had entered an ascending lumbar vein with a large retroperitoneal abscess. This case emphasized the need to confirm central venous catheter position at the time of insertion and pointed out yet another risk of parenteral alimentation.