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Empyema Necessitatis

Figure 1.
Editor's Note: The narration and closed captions in this video are in English. For subtitles in 13 other languages, see this video on the website of the World Health Organization.

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Images in Clinical Medicine

Ronaldo A. Gismondi, M.D., Ph.D., and Luiz F.F. de Souza, M.D.

N Engl J Med 2017; 376:e13February 23, 2017DOI: 10.1056/NEJMicm1608914

Article

A 40-year-old man presented with a 3-month history of fever, weight loss, dyspnea, and cough. Physical examination revealed a tender, bulging anterior thoracic mass and a small ulcerative lesion that was inferomedial to the right nipple (Panel A). Computed tomographic scans showed a pleural effusion (Panel B) that extended through the chest wall (Panel C, arrow), along with accompanying bone destruction. Surgical exploration revealed purulent pleural fluid; a culture of the fluid grew Mycobacterium tuberculosis. Empyema necessitatis is a complication of pleural empyema that is characterized by extension of purulent fluid through the parietal pleura into the chest wall. A chest tube was placed for 3 weeks; the patient was treated for 9 months with rifampin, isoniazid, pyrazinamide, and ethambutol, and he recovered fully.

Ronaldo A. Gismondi, M.D., Ph.D.
Luiz F.F. de Souza, M.D.
Fluminense Federal University, Rio de Janeiro, Brazil

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Tags: infectiology, MEDICINE
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