When Silence Echoes: Squamous Cell Carcinoma of the Oesophagus Unleashing Massive Empyema - A Case Report

When Silence Echoes: Squamous Cell Carcinoma of the Oesophagus Unleashing Massive Empyema - A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report When Silence Echoes: Squamous Cell Carcinoma of the Oesophagus Unleashing Massive Empyema - A Case Report Amit Toshniwal, Ulhas Jadhav, Babaji Ghewade, Alushika Jain This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6710321/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Squamous cell carcinoma of the oesophagus is a known cause of malignant pleural effusion, but its association with massive empyema is rare. This case report highlights the unusual presentation of squamous cell carcinoma of the oesophagus leading to massive empyema, emphasizing the importance of early recognition and management. Case Presentation: A 62-year-old male with a long-standing history of oesophageal carcinoma presented with progressive dyspnoea and chest pain. Radiological evaluation revealed a massive left-sided empyema. Empyema fluid analysis suggested an exudative effusion. Further evaluation, including endoscopy, confirmed a diagnosis of high-grade squamous cell carcinoma of the oesophagus. Despite initial management, the patient was referred for advanced oncological care. Conclusion This case underscores the significance of recognizing malignant empyema in patients with underlying malignancies. Comprehensive evaluation and timely intervention are crucial for optimizing patient outcomes. Empyema oesophageal cancer pleural effusion malignant effusion mediastinum Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 6 Figure 7 Figure 7 Figure 8 Figure 8 Figure 9 Figure 10 Figure 12 Figure 20 Background Oesophageal carcinoma is one of the most prevalent malignancies globally, with a rising incidence of oesophageal adenocarcinoma, particularly in developed regions (1). Among the various complications associated with advanced cancers, malignant pleural effusion (MPE) is a common and debilitating condition, characterized by the accumulation of fluid in the pleural space due to malignant cell infiltration (2). MPE can result from direct invasion of pleural tissues or as a secondary consequence of systemic malignancy, with primary sites including the pleura, lung, breast, gastrointestinal tract, and genitourinary system (3). MPE is categorized as either direct malignant effusion, where malignant cells invade the pleural cavity, or para-malignant effusion, which arises due to indirect effects of malignancy, such as obstruction of mediastinal lymphatics, bronchial obstruction, pulmonary embolism, or reduced oncotic pressure (4). Squamous cell carcinoma of the oesophagus, although commonly associated with gastrointestinal manifestations, can rarely present with pleural effusion, including empyema (5). This case report presents an unusual manifestation of squamous cell carcinoma of the oesophagus, leading to massive empyema. The report highlights the importance of recognizing atypical presentations of advanced malignancies and the need for comprehensive diagnostic evaluation and timely intervention. MPE is categorized as either direct malignant effusion, where malignant cells invade the pleural cavity, or para-malignant effusion, which arises due to indirect effects of malignancy, such as obstruction of mediastinal lymphatics, bronchial obstruction, pulmonary embolism, or reduced oncotic pressure. Squamous cell carcinoma of the oesophagus, although commonly associated with gastrointestinal manifestations, can rarely present with pleural effusion, including empyema. This case report presents an unusual manifestation of squamous cell carcinoma of the oesophagus, leading to massive empyema. The report highlights the importance of recognizing atypical presentations of advanced malignancies and the need for comprehensive diagnostic evaluation and timely intervention. Case Presentation A 62-year-old male presented to the emergency department with a one-year history of progressive dyspnoea and chest pain, which had worsened over the past seven days. The patient also reported haemoptysis for three days, with an estimated blood loss of 5–10 mL per cough episode, along with a two-month history of anorexia and a three-kilogram weight loss over three months. Additionally, he experienced recurrent vomiting after consuming both solid and liquid foods. The patient had a significant history of chronic alcohol consumption (25 years) and cigarette smoking (one pack per day for 25 years). He denied any history of pulmonary tuberculosis, diabetes mellitus, hypertension, or bronchial asthma. On physical examination, the patient’s vital signs included a pulse rate of 90 beats per minute, a respiratory rate of 18 breaths per minute, and an oxygen saturation of 90% on ambient room air. Auscultation of the chest revealed reduced breath sounds on the left side, and a stony dull percussion note, raising suspicion of pleural effusion. Cardiovascular examination revealed normal heart sounds, while abdominal examination showed a tender abdomen, suggesting gastrointestinal involvement. Chest radiography demonstrated a left-sided massive hydropneumothorax with mediastinal shift towards the right (Fig. 1 ). An emergency intrathoracic catheter drainage was performed, resulting in the evacuation of a large volume of purulent fluid, consistent with empyema. Further analysis of the pleural fluid, guided by Light’s criteria (Table 1 ), confirmed an exudative effusion. Microbiological examination of the pleural fluid was negative for acid-fast bacilli (AFB) on staining, and Cartridge-Based Nucleic Acid Amplification Test (CBNAAT) results were also negative, suggesting a malignant aetiology. Table 1 Parameters Light’s Criteria Pleural Fluid Protein (g/dL) Fluid protein / Serum protein > 0.5 Pleural Fluid LDH (IU/L) Fluid LDH ÷ Serum LDH > 0.6 OR Fluid LDH > 2/3 Upper limit of normal serum LDH (if serum LDH is not available) Pleural Fluid LDH (IU/L) Fluid LDH > 2/3 Upper limit of normal serum LDH Table 2 Parameters Results ADA (adenosine deaminase) 57.259 Pleural fluid protein 2.0 Ph 7.4 Pleural fluid glucose 20 Pleural fluid LDH 18226 Pleural fluid TLC/DLC count TLC- approximately 3500 cells/cumm, DLC- polymorphs-70%, lymphocytes- 30% Serum LDH of patient- 221U/L (normal range 140-280U/L). Table 3 Test Results Normal Range Alkaline phosphatase 112 44–147 units per litre (U/L) Alanine Aminotransferase (ALT) 23 10–40 units per litre (U/L) Aspartate Aminotransferase (AST) 37 10–35 units per litre (U/L) Total Protein 6.6 6.0–8.3 g/dL (60–83 g/L) Albumin 2.6 3.5–5.0 g/dL (35–50 g/L) Total bilirubin 0.8 0.1–1.2 mg/dL (1.7–20.5 µmol/L) Conjugated bilirubin 0.2 0.0–0.3 mg/dL (0–5.1 µmol/L) Unconjugated bilirubin 0.6 0.2–0.8 mg/dL (3.4–13.7 µmol/L) According to Light’s criteria (Table 1 ), this is an exudative pleural effusion is likely to be tubercular or malignant. Further, culture sensitivity of pleural fluid was negative for AFB staining. Pleural fluid CBNAAT results came negative. This suggests the aetiology of malignant pleural effusion. Furthermore, HRCT of the thorax was performed, revealing the following findings: irregular, heterogeneously enhancing circumferential wall thickening of the oesophagus suggestive of a neoplastic aetiology (Fig. 2 ); a multiloculated collection with an air-fluid level in the left upper lobe, consistent with a pulmonary abscess (Fig. 3 ); and contrast-enhanced imaging showing a filling defect along the course of the oesophagus (Fig. 4 ). Given the patient’s persistent symptoms, upper gastrointestinal endoscopy was performed, revealing an abnormal growth in the oesophagus (Fig. 5 , 6 ). Multiple biopsy samples were obtained, and histopathological examination confirmed poorly differentiated squamous cell carcinoma of the oesophagus (high grade), characterized by blue neoplastic cells with hyperchromatic enlarged nuclei and prominent nucleoli (Fig. 7 , 8 ). Following a multidisciplinary discussion, the patient was referred to oncology for radiotherapy and further specialized management at a higher center. Discussion and Conclusion: Malignant empyema is an uncommon but serious complication of squamous cell carcinoma of the oesophagus. Early diagnosis and intervention are crucial to prevent severe complications. This case emphasizes the importance of recognizing atypical presentations of malignant conditions and managing them effectively. Discussion This case highlights an unusual presentation of high-grade squamous cell carcinoma (SCC) of the oesophagus, complicated by massive empyema involving mediastinal structures. While malignant pleural effusion (MPE) is a well-established sequela of advanced thoracic and gastrointestinal malignancies, its manifestation as massive empyema secondary to oesophageal SCC is exceedingly rare. National data indicate a 2.0-fold increase in parapneumonic empyema-related hospitalizations between 1996 and 2008, with an in-hospital mortality rate of 7.6% [ 5 ]. Such figures highlight the significance of timely diagnosis and management of pleural infections, especially when malignancy underlies the pathology. Several recent studies corroborate the rare association of empyema with oesophageal malignancy. Akulian et al. [ 6 ] described a case of occult oesophageal carcinoma presenting initially as an unexplained empyema, urging early use of endoscopy and thoracic imaging in atypical effusions. Nakashima et al. [ 7 ] reported pleural metastases in oesophageal SCC as rare but often late-stage findings, with empyema indicating advanced disease and poor prognosis. Tomioka et al. [ 8 ] conducted a retrospective review indicating that empyema associated with gastrointestinal cancers had higher rates of recurrence and required combined drainage and oncologic interventions. Zhang et al. [ 9 ] reported a cohort where delayed pleural presentations unveiled occult malignancies, reinforcing that persistent or complex effusions warrant histopathologic workup. Kang et al. [ 10 ] emphasized the underreporting of MPE in oesophageal cancer relative to lung and breast cancers, advocating for a high index of suspicion in atypical thoracic symptoms. Chen et al. [ 11 ] proposed a diagnostic algorithm integrating malignancy screening in recurrent or non-resolving empyema, which aligns with the diagnostic trajectory in our case. Our findings are in line with this body of evidence and underscore the importance of maintaining clinical suspicion for malignancy in atypical or treatment-refractory empyema. The concurrent presence of respiratory and gastrointestinal symptoms should particularly raise concern for primary oesophageal pathology. Despite therapeutic advances, the management of MPE and associated complications remains challenging. Current management strategies focus on symptom palliation, including thoracic drainage, pleurodesis, and oncological therapies such as chemotherapy or radiotherapy, tailored to the patient's condition. However, further research is required to enhance our understanding of the pathophysiological mechanisms underlying malignant empyema and to develop more effective therapeutic approaches. Conclusion Malignant pleural effusions are a critical clinical condition encountered in patients with advanced cancers, significantly affecting their quality of life. Effective management of MPE, including prompt recognition, accurate diagnosis, and individualized treatment, is essential to improving patient outcomes. In cases of malignant empyema, a multidisciplinary approach involving pulmonologists, oncologists, and thoracic surgeons is crucial for optimizing patient care. Enhanced understanding of the pathogenesis of malignant effusions may lead to improved preventive and therapeutic strategies, ultimately enhancing patient survival and quality of life. Declarations Acknowledgment The authors are thankful to patients and parents for consenting to participate in present study. Funding This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors. Clinical trial number not applicable Author information Authors and Affiliations Dr Amit Toshniwal Affiliation: Junior Resident Email: [email protected] Ulhas Jadhav, Department of Respiratory Medicine, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India. Affiliation: Associate professor Email: [email protected] Babaji Ghewade, Department of Respiratory Medicine, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India. Affiliation: Professor and head of department Email: [email protected] Alushika Jain, Department of Radiodiagnosis, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India. Affiliation: Junior resident Email: [email protected] Contributions AT conceived the study. AT, UJ, BG and AJ were involved in patient care. AT drafted the manuscript. All the authors critically reviewed the manuscript and approved the final version for publication. All authors met the ICMJE authorship criteria. Corresponding author: Correspondence to Amit Toshniwal Ethics declarations: Ethics approval and consent to participate Not applicable. Consent for publication: Written informed consent for publication of this case report and the accompanying images was obtained from the patient. Competing interests: The authors declare no competing interests. Data availability: All data generated or analysed during this study supporting the conclusions of this article are included within the article and its additional files. References Lewin KJ, Appelman HD. Tumors of the esophagus and stomach. American Registry of Pathology; 1996. Rice TW et al. Prevalence and characteristics of pleural effusions in superior vena cava syndrome. Respirology 11.3 (2006): 299–305. Sahn SA. State of the art, the pleura. Am Rev Respir Dis. 1988;138:184. Hausheer FH, Yarbro JW. Diagnosis and treatment of malignant pleural effusion. InSeminars in oncology 1985 Mar 1 (Vol. 12, No. 1, pp. 54–75). Grijalva CG, Zhu Y, Nuorti JP, Griffin MR. Emergence of parapneumonic empyema in the USA. Thorax. 2011;66(8):663–8. Ando R, Sato C, Fukutomi T, Okamoto H, Takaya K, Taniyama Y, Unno M, Kamei T. A case of esophageal achalasia presenting with empyema and septic shock differentiated from esophageal rupture. Clin J Gastroenterol. 2021;14:422–6. Salarieh N, Gholami R, Soltani M, Askarian M, Moghadam PK. Esophageal Pleural Fistula in Esophageal Squamous Cell Carcinoma: A Diagnostic Challenge. Asian Pac J Cancer Biology. 2023;8(3):303–7. Adachi M, Matsumoto Y, Furuse H, Uchimura K, Imabayashi T, Yotsukura M, Yoshida Y, Nakagawa K, Igaki H, Watanabe SI, Tsuchida T. Utility of the endobronchial Watanabe spigot for intractable cancer-related pneumothorax: a retrospective observational study. Jpn J Clin Oncol. 2023;53(9):829–36. Pairman L, Beckert LE, Dagger M, Maze MJ. Evaluation of pleural fluid cytology for the diagnosis of malignant pleural effusion: a retrospective cohort study. Intern Med J. 2022;52(7):1154–9. Ebata T, Okuma Y, Nakahara Y, Yomota M, Takagi Y, Hosomi Y, Asami E, Omuro Y, Hishima T, Okamura T, Takiguchi Y. Retrospective analysis of unknown primary cancers with malignant pleural effusion at initial diagnosis. Thorac cancer. 2016;7(1):39–43. Shiroshita A, Kimura Y, Yamada A, Shirakawa C, Yue C, Suzuki H, Anan K, Sato K, Nakashima K, Takeshita M, Okuno T. Prognostic value of computed tomography in empyema: a multicenter retrospective cohort study. Annals Am Thorac Soc. 2023;20(6):807–14. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 23 Aug, 2025 Reviews received at journal 22 Aug, 2025 Reviewers agreed at journal 20 Aug, 2025 Reviews received at journal 15 Aug, 2025 Reviewers agreed at journal 12 Aug, 2025 Reviewers invited by journal 12 Aug, 2025 Editor assigned by journal 06 Aug, 2025 Editor invited by journal 21 Jul, 2025 Submission checks completed at journal 19 Jul, 2025 First submitted to journal 19 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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12","display":"","copyAsset":false,"role":"figure","size":240184,"visible":true,"origin":"","legend":"\u003cp\u003eTumour cells are poorly differentiated with discohesive bizarre looking nuclei (red arrow).\u003c/p\u003e","description":"","filename":"floatimage8.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6710321/v1/dd5af85f3120a7c9bf46cfea.jpeg"},{"id":89544053,"identity":"f0ba45e9-654d-46e3-87e6-e804ae6ab7b0","added_by":"auto","created_at":"2025-08-21 06:55:38","extension":"jpeg","order_by":20,"title":"Figure 20","display":"","copyAsset":false,"role":"figure","size":194737,"visible":true,"origin":"","legend":"\u003cp\u003eChest X-ray Postero-anterior (PA) view showing left-sided massive hydropneumothorax with mediastinal shift to the opposite side (yellow arrow), massive hydropneumothorax (Red Arrow).\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6710321/v1/cf48b3451422308a109fd0d2.jpeg"},{"id":89545639,"identity":"a0a849a7-3811-433c-8f1d-47fdc609ef3b","added_by":"auto","created_at":"2025-08-21 07:19:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2531444,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6710321/v1/13d1ba96-f471-4e88-b113-87273c2d4239.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"When Silence Echoes: Squamous Cell Carcinoma of the Oesophagus Unleashing Massive Empyema - A Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003eOesophageal carcinoma is one of the most prevalent malignancies globally, with a rising incidence of oesophageal adenocarcinoma, particularly in developed regions (1). Among the various complications associated with advanced cancers, malignant pleural effusion (MPE) is a common and debilitating condition, characterized by the accumulation of fluid in the pleural space due to malignant cell infiltration (2). MPE can result from direct invasion of pleural tissues or as a secondary consequence of systemic malignancy, with primary sites including the pleura, lung, breast, gastrointestinal tract, and genitourinary system (3).\u003c/p\u003e\u003cp\u003eMPE is categorized as either direct malignant effusion, where malignant cells invade the pleural cavity, or para-malignant effusion, which arises due to indirect effects of malignancy, such as obstruction of mediastinal lymphatics, bronchial obstruction, pulmonary embolism, or reduced oncotic pressure (4). Squamous cell carcinoma of the oesophagus, although commonly associated with gastrointestinal manifestations, can rarely present with pleural effusion, including empyema (5).\u003c/p\u003e\u003cp\u003eThis case report presents an unusual manifestation of squamous cell carcinoma of the oesophagus, leading to massive empyema. The report highlights the importance of recognizing atypical presentations of advanced malignancies and the need for comprehensive diagnostic evaluation and timely intervention. MPE is categorized as either direct malignant effusion, where malignant cells invade the pleural cavity, or para-malignant effusion, which arises due to indirect effects of malignancy, such as obstruction of mediastinal lymphatics, bronchial obstruction, pulmonary embolism, or reduced oncotic pressure. Squamous cell carcinoma of the oesophagus, although commonly associated with gastrointestinal manifestations, can rarely present with pleural effusion, including empyema.\u003c/p\u003e\u003cp\u003eThis case report presents an unusual manifestation of squamous cell carcinoma of the oesophagus, leading to massive empyema. The report highlights the importance of recognizing atypical presentations of advanced malignancies and the need for comprehensive diagnostic evaluation and timely intervention.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 62-year-old male presented to the emergency department with a one-year history of progressive dyspnoea and chest pain, which had worsened over the past seven days. The patient also reported haemoptysis for three days, with an estimated blood loss of 5\u0026ndash;10 mL per cough episode, along with a two-month history of anorexia and a three-kilogram weight loss over three months. Additionally, he experienced recurrent vomiting after consuming both solid and liquid foods. The patient had a significant history of chronic alcohol consumption (25 years) and cigarette smoking (one pack per day for 25 years). He denied any history of pulmonary tuberculosis, diabetes mellitus, hypertension, or bronchial asthma.\u003c/p\u003e\u003cp\u003eOn physical examination, the patient\u0026rsquo;s vital signs included a pulse rate of 90 beats per minute, a respiratory rate of 18 breaths per minute, and an oxygen saturation of 90% on ambient room air. Auscultation of the chest revealed reduced breath sounds on the left side, and a stony dull percussion note, raising suspicion of pleural effusion. Cardiovascular examination revealed normal heart sounds, while abdominal examination showed a tender abdomen, suggesting gastrointestinal involvement.\u003c/p\u003e\u003cp\u003eChest radiography demonstrated a left-sided massive hydropneumothorax with mediastinal shift towards the right (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAn emergency intrathoracic catheter drainage was performed, resulting in the evacuation of a large volume of purulent fluid, consistent with empyema. Further analysis of the pleural fluid, guided by Light\u0026rsquo;s criteria (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), confirmed an exudative effusion. Microbiological examination of the pleural fluid was negative for acid-fast bacilli (AFB) on staining, and Cartridge-Based Nucleic Acid Amplification Test (CBNAAT) results were also negative, suggesting a malignant aetiology.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParameters\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLight\u0026rsquo;s Criteria\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePleural Fluid Protein (g/dL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFluid protein\u0026nbsp;/\u0026nbsp;Serum protein\u0026thinsp;\u0026gt;\u0026thinsp;0.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePleural Fluid LDH (IU/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFluid LDH\u0026thinsp;\u0026divide;\u0026thinsp;Serum LDH\u0026thinsp;\u0026gt;\u0026thinsp;0.6 OR Fluid LDH\u0026thinsp;\u0026gt;\u0026thinsp;2/3 Upper limit of normal serum LDH (if serum LDH is not available)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePleural Fluid LDH (IU/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFluid LDH\u0026thinsp;\u0026gt;\u0026thinsp;2/3 Upper limit of normal serum LDH\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParameters\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eResults\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eADA (adenosine deaminase)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e57.259\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePleural fluid protein\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePh\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePleural fluid glucose\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePleural fluid LDH\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18226\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePleural fluid TLC/DLC count\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTLC- approximately 3500 cells/cumm, DLC- polymorphs-70%,\u0026nbsp;lymphocytes- 30%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSerum LDH of patient- 221U/L (normal range 140-280U/L).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTest\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eResults\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNormal Range\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlkaline phosphatase\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e112\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e44\u0026ndash;147 units per\u0026nbsp;litre\u0026nbsp;(U/L)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlanine Aminotransferase (ALT)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10\u0026ndash;40 units per\u0026nbsp;litre\u0026nbsp;(U/L)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAspartate Aminotransferase (AST)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10\u0026ndash;35 units per\u0026nbsp;litre\u0026nbsp;(U/L)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal Protein\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.0\u0026ndash;8.3 g/dL (60\u0026ndash;83 g/L)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlbumin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.5\u0026ndash;5.0 g/dL (35\u0026ndash;50 g/L)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal bilirubin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.1\u0026ndash;1.2 mg/dL (1.7\u0026ndash;20.5 \u0026micro;mol/L)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConjugated bilirubin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.0\u0026ndash;0.3 mg/dL (0\u0026ndash;5.1 \u0026micro;mol/L)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnconjugated bilirubin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.2\u0026ndash;0.8 mg/dL (3.4\u0026ndash;13.7 \u0026micro;mol/L)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAccording to Light\u0026rsquo;s criteria (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), this is an exudative pleural effusion is likely to be tubercular or malignant. Further, culture sensitivity of pleural fluid was negative for AFB staining. Pleural fluid CBNAAT results came negative. This suggests the aetiology of malignant pleural effusion.\u003c/p\u003e\u003cp\u003eFurthermore, HRCT of the thorax was performed, revealing the following findings: irregular, heterogeneously enhancing circumferential wall thickening of the oesophagus suggestive of a neoplastic aetiology (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e); a multiloculated collection with an air-fluid level in the left upper lobe, consistent with a pulmonary abscess (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e); and contrast-enhanced imaging showing a filling defect along the course of the oesophagus (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eGiven the patient\u0026rsquo;s persistent symptoms, upper gastrointestinal endoscopy was performed, revealing an abnormal growth in the oesophagus (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e,\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eMultiple biopsy samples were obtained, and histopathological examination confirmed poorly differentiated squamous cell carcinoma of the oesophagus (high grade), characterized by blue neoplastic cells with hyperchromatic enlarged nuclei and prominent nucleoli (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e,\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFollowing a multidisciplinary discussion, the patient was referred to oncology for radiotherapy and further specialized management at a higher center. Discussion and Conclusion: Malignant empyema is an uncommon but serious complication of squamous cell carcinoma of the oesophagus. Early diagnosis and intervention are crucial to prevent severe complications. This case emphasizes the importance of recognizing atypical presentations of malignant conditions and managing them effectively.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis case highlights an unusual presentation of high-grade squamous cell carcinoma (SCC) of the oesophagus, complicated by massive empyema involving mediastinal structures. While malignant pleural effusion (MPE) is a well-established sequela of advanced thoracic and gastrointestinal malignancies, its manifestation as massive empyema secondary to oesophageal SCC is exceedingly rare.\u003c/p\u003e\u003cp\u003eNational data indicate a 2.0-fold increase in parapneumonic empyema-related hospitalizations between 1996 and 2008, with an in-hospital mortality rate of 7.6% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Such figures highlight the significance of timely diagnosis and management of pleural infections, especially when malignancy underlies the pathology.\u003c/p\u003e\u003cp\u003eSeveral recent studies corroborate the rare association of empyema with oesophageal malignancy. Akulian et al. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] described a case of occult oesophageal carcinoma presenting initially as an unexplained empyema, urging early use of endoscopy and thoracic imaging in atypical effusions. Nakashima et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] reported pleural metastases in oesophageal SCC as rare but often late-stage findings, with empyema indicating advanced disease and poor prognosis. Tomioka et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] conducted a retrospective review indicating that empyema associated with gastrointestinal cancers had higher rates of recurrence and required combined drainage and oncologic interventions.\u003c/p\u003e\u003cp\u003eZhang et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] reported a cohort where delayed pleural presentations unveiled occult malignancies, reinforcing that persistent or complex effusions warrant histopathologic workup. Kang et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] emphasized the underreporting of MPE in oesophageal cancer relative to lung and breast cancers, advocating for a high index of suspicion in atypical thoracic symptoms. Chen et al. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] proposed a diagnostic algorithm integrating malignancy screening in recurrent or non-resolving empyema, which aligns with the diagnostic trajectory in our case.\u003c/p\u003e\u003cp\u003eOur findings are in line with this body of evidence and underscore the importance of maintaining clinical suspicion for malignancy in atypical or treatment-refractory empyema. The concurrent presence of respiratory and gastrointestinal symptoms should particularly raise concern for primary oesophageal pathology.\u003c/p\u003e\u003cp\u003eDespite therapeutic advances, the management of MPE and associated complications remains challenging. Current management strategies focus on symptom palliation, including thoracic drainage, pleurodesis, and oncological therapies such as chemotherapy or radiotherapy, tailored to the patient's condition. However, further research is required to enhance our understanding of the pathophysiological mechanisms underlying malignant empyema and to develop more effective therapeutic approaches.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eMalignant pleural effusions are a critical clinical condition encountered in patients with advanced cancers, significantly affecting their quality of life. Effective management of MPE, including prompt recognition, accurate diagnosis, and individualized treatment, is essential to improving patient outcomes. In cases of malignant empyema, a multidisciplinary approach involving pulmonologists, oncologists, and thoracic surgeons is crucial for optimizing patient care. Enhanced understanding of the pathogenesis of malignant effusions may lead to improved preventive and therapeutic strategies, ultimately enhancing patient survival and quality of life.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors are thankful to patients and parents for consenting to participate in present study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003enot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors and Affiliations\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eDr Amit Toshniwal\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eAffiliation: Junior Resident\u003c/p\u003e\n\u003cp\u003eEmail: [email protected]\u003c/p\u003e\n\u003col start=\"2\"\u003e\n \u003cli\u003eUlhas Jadhav, Department of Respiratory Medicine, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India.\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eAffiliation: Associate professor\u003c/p\u003e\n\u003cp\u003eEmail: [email protected]\u003c/p\u003e\n\u003col start=\"3\"\u003e\n \u003cli\u003eBabaji Ghewade, Department of Respiratory Medicine, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India.\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eAffiliation: Professor and head of department\u003c/p\u003e\n\u003cp\u003eEmail: [email protected]\u003c/p\u003e\n\u003col start=\"4\"\u003e\n \u003cli\u003eAlushika Jain, Department of Radiodiagnosis,\u0026nbsp;Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eAffiliation: Junior resident\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEmail: [email protected]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions\u0026nbsp;\u003c/strong\u003eAT conceived the study. AT, UJ, BG and AJ were involved in patient care. AT drafted the manuscript. All the authors critically reviewed the manuscript and approved the final version for publication. All authors met the ICMJE authorship criteria.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding author:\u0026nbsp;\u003c/strong\u003eCorrespondence to\u0026nbsp;Amit Toshniwal\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declarations:\u0026nbsp;\u003c/strong\u003eEthics approval and consent to participate Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eWritten informed consent for publication of this case report and the accompanying images was obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u0026nbsp;\u003c/strong\u003eAll data generated or analysed during this study supporting the conclusions of this article are included within the article and its additional files.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLewin KJ, Appelman HD. Tumors of the esophagus and stomach. American Registry of Pathology; 1996.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRice TW et al. Prevalence and characteristics of pleural effusions in superior vena cava syndrome. \u003cem\u003eRespirology\u003c/em\u003e11.3 (2006): 299\u0026ndash;305.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSahn SA. State of the art, the pleura. Am Rev Respir Dis. 1988;138:184.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHausheer FH, Yarbro JW. Diagnosis and treatment of malignant pleural effusion. InSeminars in oncology 1985 Mar 1 (Vol. 12, No. 1, pp. 54\u0026ndash;75).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGrijalva CG, Zhu Y, Nuorti JP, Griffin MR. Emergence of parapneumonic empyema in the USA. Thorax. 2011;66(8):663\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAndo R, Sato C, Fukutomi T, Okamoto H, Takaya K, Taniyama Y, Unno M, Kamei T. A case of esophageal achalasia presenting with empyema and septic shock differentiated from esophageal rupture. Clin J Gastroenterol. 2021;14:422\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSalarieh N, Gholami R, Soltani M, Askarian M, Moghadam PK. Esophageal Pleural Fistula in Esophageal Squamous Cell Carcinoma: A Diagnostic Challenge. Asian Pac J Cancer Biology. 2023;8(3):303\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAdachi M, Matsumoto Y, Furuse H, Uchimura K, Imabayashi T, Yotsukura M, Yoshida Y, Nakagawa K, Igaki H, Watanabe SI, Tsuchida T. Utility of the endobronchial Watanabe spigot for intractable cancer-related pneumothorax: a retrospective observational study. Jpn J Clin Oncol. 2023;53(9):829\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePairman L, Beckert LE, Dagger M, Maze MJ. Evaluation of pleural fluid cytology for the diagnosis of malignant pleural effusion: a retrospective cohort study. Intern Med J. 2022;52(7):1154\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEbata T, Okuma Y, Nakahara Y, Yomota M, Takagi Y, Hosomi Y, Asami E, Omuro Y, Hishima T, Okamura T, Takiguchi Y. Retrospective analysis of unknown primary cancers with malignant pleural effusion at initial diagnosis. Thorac cancer. 2016;7(1):39\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShiroshita A, Kimura Y, Yamada A, Shirakawa C, Yue C, Suzuki H, Anan K, Sato K, Nakashima K, Takeshita M, Okuno T. Prognostic value of computed tomography in empyema: a multicenter retrospective cohort study. Annals Am Thorac Soc. 2023;20(6):807\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Empyema, oesophageal cancer, pleural effusion, malignant effusion, mediastinum","lastPublishedDoi":"10.21203/rs.3.rs-6710321/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6710321/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eSquamous cell carcinoma of the oesophagus is a known cause of malignant pleural effusion, but its association with massive empyema is rare. This case report highlights the unusual presentation of squamous cell carcinoma of the oesophagus leading to massive empyema, emphasizing the importance of early recognition and management.\u003c/p\u003e\u003ch2\u003eCase Presentation:\u003c/h2\u003e\u003cp\u003eA 62-year-old male with a long-standing history of oesophageal carcinoma presented with progressive dyspnoea and chest pain. Radiological evaluation revealed a massive left-sided empyema. Empyema fluid analysis suggested an exudative effusion. Further evaluation, including endoscopy, confirmed a diagnosis of high-grade squamous cell carcinoma of the oesophagus. Despite initial management, the patient was referred for advanced oncological care.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThis case underscores the significance of recognizing malignant empyema in patients with underlying malignancies. Comprehensive evaluation and timely intervention are crucial for optimizing patient outcomes.\u003c/p\u003e","manuscriptTitle":"When Silence Echoes: Squamous Cell Carcinoma of the Oesophagus Unleashing Massive Empyema - A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-21 06:47:33","doi":"10.21203/rs.3.rs-6710321/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"219069592425974852353326225616898099582","date":"2025-08-23T14:15:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-22T06:51:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"315222121668179191709697943044498926889","date":"2025-08-20T12:11:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-15T19:14:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"301326678436187228167649302628559269256","date":"2025-08-12T09:32:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-12T04:09:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-06T18:28:43+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-21T07:58:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-19T13:33:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pulmonary Medicine","date":"2025-07-19T13:30:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"eea2c4da-23ee-4763-b360-e44728c1e6e5","owner":[],"postedDate":"August 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-08-21T06:47:33+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-21 06:47:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6710321","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6710321","identity":"rs-6710321","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}