A 52-year-old man with 40-pack year smoking history and daily alcohol consumption of 4 liters of beer was hospitalized with severe shortness of breath for one week, unproductive cough for "several months", occasional night sweats but stable body weight. On physical examination he was orthopneic with absent breath sounds and a dull percussion note were present on the left side of his chest. Vital parameters were: blood pressure 143/88 mmHg, heart rate 105/min, respiratory rate 21/min, body temperature 37.6  C, oxygen saturation 94%. Laboratory tests showed elevated inflammatory parameters and serum enzymes: C-reactive protein (CRP) 221.7 mg/l, white blood cells (WBC) 22.7 x 109/l, alkaline phosphatase (AP) 254 U/l, gamma-glutamyl transferase (yGT) 223 U/l, aspartate transaminase (ASAT) 55 U/l, alanine transaminase (ALAT) 82 U/l, lactate dehydrogenase (LDH) 285 U/l. Computed tomography (CT) of the thorax revealed a massive pleural effusion on the left with mediastinal lymphadenopathy and shift to the right side (Fig. 1 A, B). Bronchoscopy was unremarkable. Pleural tapping revealed turbid effusion fluid, a low pH of 7.15, low glucose of 1.5 mmol/l, elevated pleura/serum ratios of LDH 2.44 (normal<0.6) and of protein 0.69 (normal<0.5), all parameters suggestive of an empyema. Microscopy, however, did not show bacteriae. Especially to rule out pleural carcinomatosis, as cause of the mediastinal shift, medical thoracoscopy was performed, which besides turbid empyema fluid, revealed widespread adhesions, parietal and visceral pleural thickening, multiple septae formation, which in part were mechanically dissolved by forceps (Fig. 1 C, D, E). More than 2000 ml empyema fluid was removed, a chest tube was placed in dorsobasal position. To promote enzymatic lysis of septae and adhesions 10 mg alteplase and 5 mg dornase-alpha were instilled into the pleural cavity. The follow up chest X-ray (CXR) and CT thorax demonstrated an expanded lung and residual multiloculated pleural effusion on the left (Fig. 1 F, G). Matrix-assisted-laser-desorption-ionization-time-of-flight mass-spectrum (MALDI-TOF MS) analysis from pleural effusion fluid and septae biopsies, both retrieved during thoracoscopy, confirmed A. meyeri, susceptible to amoxicillin/clavulanic acid (AMC). Tuberculosis and malignancy were ruled out. Antibiotic treatment with intravenous AMC 2.2 g q8h were started on day 2. Because of persistent infection signs surgical minithoracotomy with empyema evacuation, complete parietal pleurectomy, decortications of the left upper and lower lobes were performed (day 6). Postsurgical respiratory insufficiency, could be successfully treated with a few days of non-invasive ventilation (NIV). Because of transient renal function impairment AMC was adjusted to 1.2 g q8h and switched to Amoxicillin (AMX) 1000 mg q8h from days 14-43. The patient gradually improved and was transferred for rehabilitation on day 19. Laboratory parameters during the following two month were unremarkable.