Post-traumatic Aspergillus niger empyema in an immunocompetent military patient: a case report

Fungal empyema is an uncommon clinical entity, and empyema attributable to Aspergillus species is exceedingly rare. The vast majority of reported cases occur in immunocompromised hosts. Empyema caused specifically by Aspergillus niger has been described only in exceptional circumstances and is virtually absent from the medical literature. We report the first documented case of post-traumatic Aspergillus niger empyema in a young, immunocompetent individual.

A 22-year-old male active-duty special forces soldier sustained a penetrating gunshot wound to the left thorax during combat. Initial management included bilateral chest drain insertion and mechanical ventilation. He was discharged after eight days in satisfactory condition. Over the subsequent months, he developed progressive pleuritic chest pain and exercise intolerance. Chest radiography first demonstrated a small right pleural effusion, and computed tomography (CT) performed eight months post-injury subsequently revealed a complex, loculated right pleural collection. Thoracoscopic exploration identified a dense inflammatory process with an encased lung beneath a thick fibrinous peel. Decortication was performed and microbiological cultures-including fungal cultures, obtained due to the atypical clinical course-were positive for Aspergillus niger in both the pleural fluid and pleural tissue. No other pathogen was identified. Histopathology as an evidence of tissue invasion by septate hyphae, was not obtained. The patient completed a six-month course of voriconazole (300 mg twice daily) with good tolerability and a favourable clinical outcome.

This case highlights the importance of maintaining a broad microbiological differential-including uncommon fungal pathogens-in post-traumatic pleural space infections with atypical or indolent presentations, even in immunocompetent patients. Early surgical intervention and targeted antifungal therapy are key to achieving a successful outcome.