Colopleural fistula with secondary fecal empyema is an exceptionally rare condition.1There is usually a significant delay before the presence of colopleural fistula is suspected to be the cause for empyema.2–4 In January 2006, a young woman in her 24th week of gestation was admitted to Hamad General Hospital in Qatar because of right-side, massive pleural effusion that was initially suspected to be empyema. The fluid was green, offensive, and had all the biochemical characteristics of empyema. Despite broad antimicrobial coverage and continuous chest tube drainage, the patient did not show signs of improvement. Interestingly, variable amounts of fluid ranging from few millimeters to 3 L were drained for > 3 d. The diagnosis was later confirmed to be colopleural fistula with fecal empyema in the right pleural cavity. Fortunately, the patient survived and made a good recovery after pleural decortication and resection of the part of colon containing the fistula. A nurse (L.T.) who was caring for the patient made a very important observation shortly after the patient’s admission and before any of the doctors had suspected the diagnosis. None of us as doctors considered her statement seriously. However, after the possibility of colopleural fistula was raised by a senior consultant and confirmed later, I realized retrospectively that her observation was logical and could have been a key point for suspicion of the diagnosis earlier should we have considered it seriously. Sister Leena informed us that the amount of empyema drained was directly related to the amount of oral intake of the patient. She emphasized that after the patient was shifted from oral feeding to IV fluids for any reason, the chest tube drainage was much reduced. I think keeping this observation in mind can be useful for early suspicion of fecal empyema secondary to colopleural fistula and reduce the delay in diagnosis. In other words, variation in the amount of empyema drained in relation to oral intake (in addition to unusually offensive fluid and growth of colonic flora in pleural fluid [eg, Escherichia coli]) should raise the possibility of colopleural fistula.