Milky Tea-Colored Pleural Effusion: Empyema Complicated by Pneumothorax Due to Mixed Infection With Mycobacterium tuberculosis and Aspergillus fumigatus.

BACKGROUND Empyema is the accumulation of infected fluid within the pleural cavity, sometimes accompanied by pneumothorax. Bacterial empyema is the most common. Tuberculous and fungal empyema are less common and can occur in immunocompromised patients. Empyema caused by mixed infection with both tuberculosis and fungal pathogens is even less common. CASE REPORT This report describes a 76-year-old male lung cancer patient admitted to the hospital with fever and cough. He was receiving tislelizumab immunotherapy before admission. Chest CT at admission revealed pneumonia. Following empirical antimicrobial therapy, the pneumonia showed no improvement. He refused bronchoscopy; therefore, a sputum sample was delivered for tNGS testing. Sputum tNGS testing indicated mixed infection with Acinetobacter baumannii, Stenotrophomonas maltophilia, Klebsiella pneumoniae, Streptococcus pneumoniae, Aspergillus fumigatus, Aspergillus flavus, and COVID-19. Following adjustment of the antimicrobial regimen based on pathogenetic findings, he developed empyema complicated by pneumothorax. A chest tube was inserted, resulting in improvement of empyema and pneumothorax symptoms. Bacterial, fungal, and Mycobacterium tuberculosis cultures of the pleural effusion were all negative. Further tNGS analysis of the pleural effusion revealed a mixed infection with Mycobacterium tuberculosis and Aspergillus fumigatus. The patient refused further treatment and died 5 days after discharge. CONCLUSIONS Diagnosis of tuberculous empyema and fungal empyema is challenging and the prognosis is poor. In patients with malignant tumors, particularly those receiving immunotherapy, the possibility of Mycobacterium tuberculosis infection and fungal infections should be fully considered when infections occur, and early diagnosis and treatment are essential.