A 54-year-old man with underlying diabetes, hypertension, and smear negative pulmonary tuberculosis (diagnosed via positive sputum Xpert  Mycobacterium tuberculosis/rifampicin assay) on day 56 of intensive phase therapy was referred to our centre for further management of a complex left pleural effusion. Clinically he was tachypnoeic with a respiratory rate of 30/minute, heart rate of 110/minute and febrile at 38  C. Oxygen saturation was 93% on 3L of oxygen.
The infective blood parameters were raised (Table 1). Chest radiograph revealed left moderate pleural effusion (Fig. 1I). CT thorax showed multifocal empyema and lung abscess (Fig. 1J). Blood and pleural culture were negative. He was started on tazobactam/piperacillin which was escalated to meropenem after 72 hours in view of persistent fever and raised infective parameters.
ICC was inserted which drained minimal amount of purulent fluid. Pleural fluid analysis are listed in Table 1.
IPFT was decided; he received 3 doses of alteplase 16 mg and DNase 5 mg as per our protocol. Subsequent drainage increased to 1.1 L. The fever and breathlessness resolved and there was improvement of infective parameters. Chest radiograph (Fig. 1K) showed improvement of the effusion. He was discharged with amoxycillin/clavulanate 625 mg thrice daily for 4 weeks and maintenance therapy of anti-TB. A repeat CT thorax done on follow-up in clinic a month later, showed complete resolution of empyema (Fig. 1L).