Right-Sided Bilothorax With Secondary Empyema: A Rare Thoracic Manifestation

Bilothorax, the presence of bile in the pleural cavity, is a rare and potentially life-threatening condition. It may occur spontaneously or following hepatobiliary interventions, with right-sided involvement being most common. Patients are at substantial risk of developing empyema and require prompt drainage and intravenous antibiotic therapy. We report a 41-year-old male presenting with progressive dyspnea and bilious pleural effusion. Imaging and pleural fluid analysis confirmed right-sided bilothorax, supported by a pleural-to-serum bilirubin ratio > 1. Cultures later identified Staphylococcus aureus, indicating superimposed empyema. No prior hepatobiliary surgery was documented. Despite initial improvement with antibiotics and drainage, persistent pleural discharge and diaphragmatic injury warranted surgical intervention. Intraoperative findings revealed a 1 cm right hemidiaphragm defect with biliary contamination. Decortication and diaphragmatic repair using an abdominal wall fascial flap were performed. The patient showed clinical improvement postoperatively but declined follow-up and later succumbed to sepsis. This case highlights the importance of early recognition, appropriate drainage, and timely surgical management for bilothorax complicated by empyema.