Figure 1. The yellowish secretions from the patient’s left chest wall.
On examination, he was ill, tachypneic (30 breaths per minute), and febrile, with a corrected axillary temperature of 38.9. His oxygen saturation in room air was 90%, and his blood pressure was within normal limits. There were multiple enlarged, tender supraclavicular and axillary lymph nodes observed on the left side. The lymph nodes measured approximately 0.5 cm and were found to be mobile with a firm consistency.
On the chest examination, a visible scar from the previous chest tube was observed on the left side of the chest. In proximity to the chest tube scar, a fistula measuring 2 cm was detected. The tract was found to be actively discharging yellowish, purulent drainage. In chest auscultation, breath sounds were reduced in the left lower zone of the lung with few crepitations. Other systemic examinations were found to be normal.
The patient visited a physician with the mentioned complaints and was prescribed oral therapy consisting of clindamycin capsules 150 mg four times daily and cephalexin capsules 250 mg four times daily. Nonetheless, due to the lack of improvement, the patient was referred to Kerman Afzalipour Hospital for further assessment and management.
Laboratory testing revealed leukocytosis with a white blood cell count of 17\(\times\)\(10^{3}\)per mmᶟ with a neutrophil predominance of 80%, normocytic anemia with hemoglobin of 9.7 g/dl, a mean corposcular volume of 79  fl and a platelet count of 435\(\times\) \(10^{3}\)per mmᶟ. The initial blood sample analysis indicated a C-reactive protein level of 112 mg/dl and an erythrocyte sedimentation rate (ESR) of 44 mm/h.
Based on the patient’s history and physical examination, a chest radiograph was performed to evaluate the patient’s clinical status. A radiological investigation revealed the existence of a mass-like lesion in the left lower lobe. A chest CT scan was remarkable for left lower lobe cosolidation and loculated effusion, which contain air bubbles in favor of empyema (Figure 2).