Trans-thoracic Extension of a Lung Abscess With a Pleurocutaneous Fistula: A Report of a Rare Case

Lung abscesses are localized collections of pus within the pulmonary parenchyma, usually arising from necrotizing infection and commonly occurring in patients with risk factors such as immunosuppression or aspiration. Typical complications include pleural effusion, empyema and bronchopleural fistula. Direct invasion of the chest wall by a lung abscess is an exceptionally rare complication, with most reported cases related to tuberculous empyema (empyema necessitans) rather than being related to the primary pulmonary infection. The authors report a case of a 42-year-old male patient with chronic hepatitis C, former intravenous drug use, and active smoking, who presented with right-sided pleuritic chest pain, productive cough, dyspnea and progressive swelling of the right anterior chest wall. Computed tomography revealed a large multiloculated abscess in the right upper lobe, measuring 13 x 8 x 7.5 cm, with direct trans-thoracic extension through the intercostal space and invasion of the right pectoralis major muscle, consistent with a pleurocutaneous fistula. Microbiological studies identified methicillin-sensitive Staphylococcus aureus as the causative organism. The patient was successfully treated with surgical drainage and prolonged antibiotic therapy, resulting in complete clinical and radiological resolution. This report presents an extremely rare presentation of lung abscess with pleurocutaneous fistulization in the absence of empyema or tuberculosis, emphasizing the critical role of computed tomography in diagnosis and management.