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A 43-year-old man presented to the emergency room in respiratory distress after a 3-week illness. He had a history of alcoholism but no other serious illness. He had a respiratory rate of 34 breaths per minute, a heart rate of 120 beats per minute, a blood pressure of 80/50 mm Hg, and oxygen saturation of 86% while breathing ambient air. On examination, his neck veins were grossly distended (Panel A) and breath sounds were absent on the right side. Chest radiography revealed complete opacification of the right lung field (Panel B). The right side of the diaphragm was inverted and compressing the liver inferiorly, and the heart was hyperkinetic and severely compressed. Computed tomography showed a large collection of liquid in the right pleural space with a marked mediastinal shift and compression of the heart and great vessels toward the left side of the chest wall (Panel C). Six liters of pus was drained with the use of a 24-French chest tube, and the heart rate decreased to 90 beats per minute, the blood pressure normalized to 110/60 mm Hg, and the elevated jugular venous pressure immediately resolved (Panel D). The microbiologic culture yielded Streptococcus anginosus and S. constellatus, organisms that appeared to be associated with aspiration pneumonia. The patient was treated with ceftriaxone and clindamycin. After local fibrinolytic therapy and thoracoscopy with decortication, he had a full recovery.
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