CASE PRESENTATION: Pt is 37 y/o f who presented with fevers and dyspnea and chest-x-ray showed a large left sided pleural effusion. Pt had thoracocenthesis, drained 1.5L colorless fluid, and cell count: 1540 WBC, 88% lymphocytes, 4% mono, LDH: 352, glucose: 134, protein: 4.7 cholesterol: 119. After 2 hours, pleural fluid re-accumulated and lung did not expand. Pig tail placement with minimal drainage. Repeated chest CT showed atelectatic lung with thick rind and remaining pleural fluid. ADA level: 6.5. PPD was positive 20mm by 15mm. PT had a left sided VATS showing thickened and inflamed pleura rind with loculated fluid collections. Pleural biopsy showed necrotizing granuloma.