Late Recurrence of Empyema More Than a Decade after Window Thoracostomy: Secondary Aspergillus Infection Superimposed on Prior MRSA Empyema, Successfully Managed by Stepwise Surgical and Endobronchial Definitive Closure

Background: Fungal empyema is uncommon and has worse short-term outcomes than bacterial disease, particularly when a bronchopleural fistula (BPF) sustains contamination. Case: A previously healthy male developed BPF and methicillin-resistant Staphylococcus aureus (MRSA) empyema after right upper lobectomy at age 17, managed by open-window thoracostomy (OWT). An apical residual space persisted and formed a fungus-ball-like nodule. At age 30, he re-presented with fever and nodule growth, with elevated Aspergillus IgG; voriconazole was started. Management: Computed tomography-guided catheter placement and re-OWT exposed air leaks and recurrent MRSA. Staged fistula control with endobronchial Watanabe spigots, n-butyl-2-cyanoacrylate, and cavity-side suturing achieved cessation. Outcome: After irrigation, sterilized cultures, negative-pressure therapy preceded latissimus dorsi flap obliteration. He was discharged on postoperative day 149 without recurrence. Conclusions: A stepwise plan—source control, fistula control, sterilization, and obliteration—can achieve durable cure in mixed Aspergillus–MRSA empyema with BPF after prior OWT.