Empyema Necessitans

dok_zlo — 04.12.2025

A 66-year-old man with chronic obstructive pulmonary disease presented to the emergency department with a 2-week history of shortness of breath and cough and 5 days of left flank pain. Two days before presentation, he had noted the appearance and rapid expansion of a mass on his left side. On physical examination, there were diminished breath sounds at the base of the left lung, along with a tender mass on his lateral back on the left side (Panel A). Computed tomography of the chest showed consolidation of the left lower lobe associated with a small multiloculated pleural effusion containing gas. The pleural effusion had peripheral enhancement and extended into the left posterior lateral thoracic wall beyond the field of view of the imaging (Panel B, axial view; and Panel C, coronal view). A diagnosis of empyema necessitans — a rare complication of empyema in which the infection extends beyond the parietal pleura into the chest wall — was made. Incision and drainage of the chest-wall mass was performed. Cultures of pleural fluid grew Streptococcus intermedius. Sputum cultures were negative for tuberculosis. The patient completed a prolonged course of antibiotic therapy, and his symptoms and radiographic findings had abated by the 6-month follow-up. Adeoluwa Ayoola, M.D., and Kreshnik Zejnullahu, M.D.
Published December 3, 2025
N Engl J Med 2025;393: e38
DOI: 10.1056/NEJMicm2504921
VOL. 393 NO. 22

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