When a Lung Collapses: A Case of Polymicrobial Empyema Presenting as Massive Hydropneumothorax

Aspiration-related pneumonia can progress to empyema and massive hydropneumothorax, potentially fatal complications not frequently documented in the literature. Patients with structural lung disease and poor dentition can be particularly vulnerable to severe polymicrobial infections arising from seemingly minor aspiration events. We report the case of a man in his early 70s with chronic bronchiectasis, heart failure with reduced ejection fraction, coronary artery disease status post coronary artery bypass grafting, type 2 diabetes mellitus, chronic kidney disease, and poor dentition who presented with progressive dyspnea and acute hypoxemic respiratory failure. Imaging demonstrated a massive right-sided hydropneumothorax with complete right lung collapse and mediastinal shift. Pleural fluid cultures grew Streptococcus anginosus and Prevotella nigrescens, consistent with aspiration-related polymicrobial empyema. His hospital course was complicated by septic shock requiring vasopressor support, atrial flutter with rapid ventricular response requiring synchronized cardioversion, and pulseless ventricular tachycardia with successful return of spontaneous circulation. Management included chest tube drainage, broad-spectrum intravenous antibiotics followed by de-escalation, invasive hemodynamic monitoring, and multidisciplinary critical care support. Despite severe multiorgan compromise, the patient ultimately improved and was discharged home on prolonged oral antibiotic therapy. This case illustrates how a seemingly simple aspiration event can progress into catastrophic pleuropulmonary disease with life-threatening cardiopulmonary collapse. Early recognition, prompt source control, and multidisciplinary management were critical to improving the outcome for this patient.