Streptococcus pyogenes-Induced Necrotizing Pneumonia With Pleural Effusion in a Child: Role of Medical Thoracoscopy.

BACKGROUND Necrotizing pneumonia (NP) is a severe, life-threatening pediatric pulmonary infection associated with substantial diagnostic and therapeutic challenges, often leading to rapid lung tissue destruction, cavitation, and pleural complications that demand urgent, multidisciplinary clinical management. Flexible bronchoscopy (FB) with bronchoalveolar lavage (BAL) is a well-established tool for pathogen identification, yet the role of medical thoracoscopy in managing refractory pleural effusion in pediatric NP caused by Streptococcus pyogenes, an uncommon but highly virulent pathogen, has not been fully elucidated in clinical practice. CASE REPORT A 7-year-old girl with persistent fever, cough and acute abdominal pain was transferred due to ineffective azithromycin and corticosteroid therapy. Pharyngeal swab detected human metapneumovirus, and FB combined with BAL identified S. pyogenes as the lung pathogen. She initially responded to linezolid plus ceftriaxone but was readmitted 12 hours later with recurrent symptoms. Contrast-enhanced chest computed tomography (CT) confirmed bilateral lower lobe NP with cavitation and pleural effusion. The patient recovered uneventfully after medical thoracoscopy with closed chest drainage, and no adverse outcomes were reported at 1-, 3-, and 6-month telephone follow-ups. CONCLUSIONS This case highlights that FB and BAL are pivotal for the accurate etiological diagnosis of S. pyogenes-induced NP in children, even in the setting of concurrent viral infection, enabling targeted antimicrobial therapy selection. Medical thoracoscopy is a safe and effective minimally invasive intervention for managing refractory pleural effusion and empyema associated with severe pediatric NP, addressing mechanical obstruction and pleural complications that are unresponsive to antimicrobial monotherapy.