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Case Reports
. 2025 Jun 14;17(6):e86024.
doi: 10.7759/cureus.86024. eCollection 2025 Jun.

A Rare Case of Polymicrobial Empyema Associated With COVID-19 Infection Complicated by a Bronchopleural Fistula

Dhiraj R Regmi  1 , Sandeep Kshetri  2 , Laxman Wagle  3 , Sabita Regmi  4
Affiliations
Case Reports

A Rare Case of Polymicrobial Empyema Associated With COVID-19 Infection Complicated by a Bronchopleural Fistula

Dhiraj R Regmi et al. Cureus. .

Abstract

Empyema is a rare but serious complication in patients with COVID-19, and its association with bronchopleural fistula (BPF) is even more uncommon. We present the case of a 40-year-old woman with a history of intravenous drug use who developed polymicrobial empyema in the setting of COVID-19, further complicated by BPF. She presented with hypoxic respiratory failure, leukocytosis, and lactic acidosis. Imaging revealed a large right-sided hydropneumothorax and bilateral lung opacities. Broad-spectrum antibiotics, antivirals, and corticosteroids were initiated, and 3 liters of purulent fluid were drained via chest tube, confirming empyema. Cultures identified multiple pathogens, including Bacteroides fragilis, Arcanobacterium hemolyticum, methicillin-sensitive Staphylococcus aureus, and Group C/G streptococci. Persistent air leak and incomplete lung re-expansion led to a diagnosis of BPF. The patient was successfully managed with prolonged antibiotic therapy and chest tube drainage without requiring surgical or bronchoscopic intervention. This case highlights the importance of recognizing and conservatively managing small BPFs in COVID-19-associated empyema, emphasizing the potential for non-surgical resolution in select cases.

Keywords: antibiotics; bacterial superinfection; bronchopleural fistula; covid pneumonia; covid-19; empyema; pleural fistula; polymicrobial; thoracostomy.

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Conflict of interest statement

Human subjects: Informed consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Figures

Figure 1
Figure 1. Initial chest X-ray on presentation ​​demonstrating a large right hydropneumothorax (marked with arrow) and left retrocardiac consolidation concerning pneumonia
Figure 2
Figure 2. Chest CT with contrast on Day 3 showed decreased fluid component but a stable large amount of air within the right hydropneumothorax (arrow)
Figure 3
Figure 3. Chest CT on Day 9 showed persistent right-sided large pneumothorax (arrow) despite an indwelling thoracotomy tube and improving consolidation
Figure 4
Figure 4. Chest CT on Day 40 showing the right-sided chest tube in place (arrow), patchy, right base rounded atelectasis and left base atelectasis
See this image and copyright information in PMC

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