Recurrent Chest Infections to Chest Wall Swelling: Empyema Necessitans as an Unusual Presentation of Tuberculosis

Empyema necessitans is a rare complication of pleural infection in which infected pleural fluid extends through the parietal pleura into the surrounding soft tissues.We report the case of a 32-year-old man of Indian origin living in the United Kingdom who presented with worsening right-sided pleuritic chest pain, several months of night sweats, and a persistent dry cough.Five months earlier, he had been treated for right-sided pneumonia complicated by a pleural effusion, with persistent radiographic abnormalities on follow-up.Examination revealed reduced right-sided air entry and a tender, fluctuant swelling over the right posterior chest wall.Contrast-enhanced computed tomography demonstrated a posterior pleural collection extending through the chest wall into the adjacent paraspinal musculature, consistent with empyema necessitans.Ultrasound-guided aspiration yielded frank purulent fluid.Routine bacterial, anaerobic, and fungal cultures were negative.Acid-fast bacilli were not seen on initial microscopy; however, mycobacterial culture became positive after seven days, and polymerase chain reaction (PCR) testing of the pleural fluid detected Mycobacterium tuberculosis complex.Whole-genome sequencing subsequently identified a lineage 1 East-African-Indian-Ocean isolate with predicted susceptibility to first-line antituberculous agents.Fourdrug antituberculous therapy was commenced, with subsequent clinical and radiological improvement.This case highlights chest wall swelling as an unusual presentation of tuberculosis and emphasizes the importance of cross-sectional imaging and targeted mycobacterial testing in establishing the diagnosis.