Empyema is the collection of pus in the pleural cavity and most times, it occurs unilaterally. It is often associated with underlying pneumonia, but other causes have been identified as well. When it occurs after an esophageal perforation, which in itself is also rare, morbidity and mortality are even higher. Esophageal perforation can cause life-threatening complications due to its close proximity to the vital organs of the mediastinum, necessitating its timely diagnosis and aggressive management. Bacteria forming part of the normal esophageal and oral flora are the most common causative pathogens for empyema from an esophageal perforation. Streptococcus constellatus and group C Streptococci, though both rare and often not taken seriously, have been identified as individual causes of empyema. We present a case of a 58-year-old male who presented with a worsening cough, chest pain, and shortness of breath after choking on a fish bone. He was diagnosed with bilateral loculated empyema resulting from esophageal perforation with the pleural fluid culture isolating both group C streptococcus and Streptococcus constellatus. He also developed respiratory failure, mediastinitis, and septic shock. This case will enable physicians to take empyema caused by these bacteria seriously and also to include esophageal perforation as a differential diagnosis when a patient presents with bilateral empyema associated with chest pain and electrocardiographic changes.
Keywords: atrial fibrillation; bilateral empyema; co-infection; diffuse st elevations; esophageal perforation; group c streptococcus; mediastinitis; septic shock; streptococcus constellatus.
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