Empyema Necessitatis: A Rare Complication of Empyema.

Empyema necessitatis (EN) is an exceedingly rare complication of empyema. EN refers to the expansion and progression of an empyema beyond the thoracic cavity toward the skin wall. Herein, we present the case of a man with EN and detail his clinical course. A 42-year-old male with a prior history of substance use presented to the emergency department with three weeks of fever, cough, and progressively worsening pain overlying the left anterior chest wall. An empiric antibiotic regimen of cefepime, metronidazole, and vancomycin was initiated. Chest X-ray, ultrasound, and chest CT demonstrated a large region of loculation suspicious for a loculated empyema. On day 4 of admission, he underwent a video-assisted thoracoscopy followed by a left minithoracotomy, which confirmed the diagnosis of EN. The patient was discharged on hospital day 16 with marked clinical improvement and monitored for a year via an outpatient clinic. Symptoms did not recur, and there was complete resolution of EN. More predominant in the pre-antibiotic era with the progression of uncontrolled infections, EN is less commonly seen today. As such, EN requires a high degree of clinical suspicion for timely detection and management. Our case illustrates the importance of early intervention with antibiotics and surgical drainage.