A 31-year-old Indian man was referred for management of his pleural empyema. He had a 6-month history of productive cough, weight loss, and night sweats. His chest radiograph showed a large left pleural effusion (Fig 3
, top left). Thoracentesis yielded lymphocytic exudative fluid, and closed pleural biopsies showed necrotizing granulomatous inflammation and were culture positive for acid-fast bacilli. He started quadruple antituberculous chemotherapy with rifampicin, isoniazid, pyrazinamide, and ethambutol. After initial complete chest tube drainage (12F Seldinger chest drain; Rocket Medical PLC; Washington, Tyne & Wear, UK), the effusion recurred and when resampled was turbid with a pleural fluid pH of 6.97, a glucose concentration of 1.0 mmol/L, and a lactate dehydrogenase concentration of 5,476 IU/L. The patient remained febrile.